New Jersey Department of Health J-1 VISA WAIVER / CONRAD 30 ATTACHMENT D PHYSICIAN J-1 STATEMENTS DECLARATION OF PENDING INTERESTED GOVERNMENT AGENCY I, hereby declare and certify, penalty of the provisions of 18 _________________________ U.S.C. 1001, that I do not now have pending nor am I submitting during the pendency of this request, another request to any United States Government department or agency or any State Department of Public Health, or equivalent, other than the New Jersey Department of Health to act on my behalf in any matter relating to a waiver of my two-year-home-country physical presence requirement. Physician Signature Date MEDICAL LICENSE AFFIDAVIT I, _________________________ hereby affirm, that to the best of my knowledge, my medical license has never been suspended or revoked and that I am not subject to any criminal investigation or proceedings by any medical authority. Physician Signature Date
New Jersey Department of Health J-1 / CONRAD 30 ATTACHMENT D PHYSICIAN J-1 VISA WAIVER STATEMENTS DECLARATION OF PENDING INTERESTED GOVERNMENT AGENCY I, _________________________ hereby declare and certify, penalty of the provisions of 18 U.S.C. 1001, that I do not now have pending nor am I submitting during the pendency of this request, another request to any United States Government department or agency or any State Department of Public Health, or equivalent, other than the New Jersey Department of Health to act on my behalf in any matter relating to a waiver of my two-year-home-country physical presence requirement. Physician Signature Date MEDICAL LICENSE AFFIDAVIT I, _________________________ hereby affirm, that to the best of my knowledge, my medical license has never been suspended or revoked and that I am not subject to any criminal investigation or proceedings by any medical authority. Physician Signature Date