1. Year:* (Required) ---20092010
2. Season:* (Required) ---WinterSummer
3. First Name:* (Required)
4. Last Name:* (Required)
5. DS-2019 Number:* (Required)
   (located above the bar code in the upper right corner of your form.) You must include the N followed by the number.
6. Country of Residence:* (Required) --Select One--AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAshmore And Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas Da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic Republic Of Cook IslandsCoral Sea IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern And Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle Of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan De Nova IslandKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMartiniqueMauritiusMayotteMexicoMicronesia, Federated States OfMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew ZealandNeutral ZoneNew CaledoniaNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalauPanamaParacel IslandsPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSouth KoreaSpainSpratly IslandsSri LankaStatelessSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTuvaluTurks And Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And FutunaWest BankWestern SaharaYemenZambiaZimbabwe
7. Country of Citizenship:* (Required) --Select One--AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAshmore And Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas Da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic Republic Of Cook IslandsCoral Sea IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern And Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle Of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan De Nova IslandKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMartiniqueMauritiusMayotteMexicoMicronesia, Federated States OfMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew ZealandNeutral ZoneNew CaledoniaNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalauPanamaParacel IslandsPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSouth KoreaSpainSpratly IslandsSri LankaStatelessSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTuvaluTurks And Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And FutunaWest BankWestern SaharaYemenZambiaZimbabwe
8. Business Name:* (Required)
9. Employer City:* (Required)
10. Employer State:* (Required) --Select One--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew BrunswickNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
11. Work Start Date:

    Month Select monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day Select day01020304050607080910111213141516171819202122232425262728293031 Year Select year20092010
12. Work End Date:

    Month Select monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day Select day01020304050607080910111213141516171819202122232425262728293031 Year Select year20092010
13. Position Held:

Orientations

1. 1) How was the orientation in your home country?

2. 2) Tell us about the partner organization in your home country. Please rate the home country organization on the following (1 = bad, 5 = excellent), and add any additional comments.

   A) Helpful

   1 2 3 4 5
   Comments
   B) Organized

   1 2 3 4 5
   Comments
   C) Easy to contact

   1 2 3 4 5
   Comments
   D) On time with materials

   1 2 3 4 5
   Comments
   E) Friendly

   1 2 3 4 5
   Comments
   F) Informative

   1 2 3 4 5
   Comments
   G) Knowledgeable

   1 2 3 4 5
   Comments
   H) Honest

   1 2 3 4 5
   Comments
3. 3) How much did you pay for the program?
4. 4) Did the arrival orientation in NYC prepare you for your stay in the USA? Please give us suggestions to improve it (for example, speak slower, tell us more about taxes, give us better directions, etc.).
5. 5) Also, please tell us who gave your orientation: AlexisCaseyErikJamesKevinSarah

Employment

1. 1) Tell us what you did at work.
2. 2) Was the position what you expected? Were you disappointed?
3. 3) What was the best part of your job? What was the worst part of your job?

4. 4) Please rate your accommodations and explain your ratings: (1= bad, 5 = excellent. If not applicable, put n/a)

   A) Housing

   1 2 3 4 5
   Comments
   B) Meals

   1 2 3 4 5
   Comments
   C) Linens (sheets, towels etc)

   1 2 3 4 5
   Comments
   D) Transportation to/from work

   1 2 3 4 5
   Comments
5. 5) What were the 3 best things about your employer? What were the 3 worst things about your employer?
6. 6) Considering the number of hours worked, your duties, etc. do you feel your salary was fair? (Please do not forgot to take into account other benefits received, such as low-cost housing and meals.)
7. 7) What were your:

   Total earnings (InterExchange job)? Total earnings (other jobs, if applicable)?
8. 8) Did you get a second job? If yes, please give us the following information:

   Name of your employer: Manager/Supervisor Address: City: State: --Select One--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew BrunswickNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: Phone number:
9. 9) Please tell us what you did and if you enjoyed your second job:
10. 10) What did you spend most of your earnings doing and/or buying? Did you have fun in your free time?
11. 11) Would you recommend that InterExchange place future participants in the position you had this summer? Why or why not?

USA

1. 1) Did you travel in the USA? If yes, for how long and where? What means of transportation did you use (bus, car, train, etc.)?
2. 2) Did you make friends from the USA or other international friends during your stay? Please tell us stories!
3. 3) Do you feel your English has improved during your stay? How did your level of English affect your experience?
4. 4) What did you miss most about your home country (other than food!)? What is the first thing you will do when you go home?
5. 5) How has your idea of America changed after living and working here?
6. 6) What was your most interesting experience (positive or negative) in the United States? Tell us the funniest thing that happened to you while you were here.
7. 7) What was the craziest thing you did or saw while in America (be honest!)?

InterExchange

1. 1) Did you seek assistance from InterExchange during your stay? If yes, whom did you speak with and was he or she helpful?
2. 2) Was the InterExchange Work/Travel program what you expected? Please explain.
3. 3) Would you recommend this program to your friends? Why or why not?
4. 4) Would you be willing to speak to prospective future participants? If yes, please give us a contact phone number or email address: