J-1 Visa Refusal: Additional Information
I herby authorize the APPNA Young Physician and Advocacy/legislative Committees to contact Congressmen, My training program, U.S Department of State, Congressmen, other Government departments and legislative authorities (as deemed necessary) on my behalf.
Name *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Reason for J-1 Application *
Training Program Name *
Residency Speciality (e.g., Internal Medicine, etc.) *
Residency Program City *
Residency Program State *
Residency Program Director (PD) Name *
Residency PD/Coordinator Phone Number *
Residency PD/Coordinator E-mail *
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