DECLARACIÓN JURAMENTADA

DECLARACIÓN JURAMENTADA Yo, con número de cédula de ciudadanía No., de nacionalidad Ecuatoriana, soltero(a), de años y con domicilio en en la ciudad de, por el presente documento declaro lo siguiente.------------------------------------------------------------------------- PRIMERO.- Que entiendo y acepto todos los términos del programa WORK AND TRAVEL auspiciado por TOGETHER S.A., el cual ha sido explícitamente detallado por uno de los colaboradores de TOGETHER S.A. y que los que se puntualizarán en la presente declaración. SEGUNDO.- Declaro que es de mi conocimiento que el programa incluye.- 2.1. Posicionamiento en un trabajo TEMPORAL en los Estados Unidos de América. 2.2. Asignación específica de vivienda cerca del sitio de trabajo. 2.3. Asistencia en trámites de visa de trabajo J-1. 2.4. Entrega del formulario DS2019, documento necesario para la obtención de Visa de Trabajo J-1. 2.5. Cuatro charlas de orientación: previo a la entrevista con el empleador, antes de la cita de visa, charla de salida en Ecuador y de arribo en Estados Unidos. 2.6. Asistencia de un coordinador en los Estados Unidos. 2.7. Asistencia para la obtención del seguro medico por enfermedad y de accidentes. 2.8. Asesoramiento en el proceso de afiliación a la seguridad social. TERCERO.- Declaro que conozco los servicios que NO incluye el sistema WORK AND TRAVEL proporcionado por la compañía TOGETHER S.A. y que son los siguientes.- 3.1. Valor correspondiente a la prueba de suficiencia en inglés (costo de $10). 3.2. Costos de viajes (boletos aéreos, terrestres o marítimos, tasas de embarques, impuestos etc.) hasta el destino final de llegada. 3.3. Costos de Visa y Pasaportes (costo de citas, aplicaciones, formularios, etc) 3.4. Impuesto SEVIS. 3.5. Costos de alojamiento, alimentación ni movilización en Estados Unidos. 3.6. La obtención de los documentos para la obtención de la visa que demuestren solvencia económica para la subsistencia en Estados Unidos y demás documentación de tipo personal. 3.7. El seguro es médico por enfermedad, por lo que no incluye seguro contra catástrofes o de vida. No aplica para enfermedades prexistentes. 3.8. Cualquier otro valor no especificado en el programa CUATRO.- CONDICIONES: Declaro reunir las siguientes condiciones exigidas por TOGETHER S.A. 4.1. Ser universitario. 4.2. Edad entre los 18 a 25 años. 4.3. Nivel de inglés aceptable (70% ingles conversacional) 4.4. Aprobar una entrevista con los Coordinadores en Ecuador QUINTO.- PROCEDIMIENTOS: 5.1. Declaro que conozco el procedimiento establecido por el sistema WORK AND TRAVEL proporcionado por TOGETHER S.A., en el cual deberé realizar un pago por concepto de examen del idioma Inglés, valor no incluido en el pago por el servicio del sistema (costo de $10). En caso que el aspirante haya culminado o esté estudiando en instituciones de enseñanza de inglés podrán presentar el diploma o un certificado del nivel en que se encuentran. Dichos aspirantes rendirán el examen de suficiencia sin ningún costo. 5.2. Para acceder a la entrevista con el empleador, deberá realizar el PRIMER pago ($380), previa entrevista con el Coordinador en Ecuador y calificación de suficiencia del examen del idioma Inglés. TOGETHER S.A. no se responsabiliza por la no aceptación del empleador al trabajo aplicado. De no DECLARACION JURAMENTADA DE PRESTACION DE SERVICIOS TOGETHER S.A. Página 1 de 2

cumplir con las condiciones del empleador, TOGETHER S.A. retendrá Ciento cincuenta 00/100 dólares de los Estados Unidos de América (USD$150.00) del valor inicial, el cual representa gastos administrativos no reembolsables. 5.3. De ser aceptado por el empleador, deberé realizar un SEGUNDO pago ($510) para poder firmar el contrato de trabajo con el empleador. 5.4. Declaro que al firmar el contrato con el empleador extranjero, que no existe relación de carácter laboral entre TOGETHER S.A. y mi persona, por lo que la compañía no tiene responsabilidad alguna sobre tales obligaciones, ni aún a título de solidaridad. 5.5. Una vez firmado el contrato, previo a la entrevista con el Cónsul de los Estados Unidos de América, deberé cancelar un TERCER y pago final ($380) a TOGETHER S.A. correspondiente al envío de documentos internacionales proporcionados para la aplicación de la visa; de no ser concedida la visa solicitada, la compañía queda autorizada a retener del valor pagado, el monto de cuatrocientos ochenta 00/100 dólares de los Estados Unidos de América (USD$480.00), valor que representa el costo de los documentos entregados. 5.6. Conozco que TOGETHER S.A. no garantiza bajo ningún concepto la aprobación de la Visa que es un acto discrecional del Consulado Norteamericano. SEXTO.- Declaro que toda comunicación ya sea de pagos, procesos, documentos, entre otros que recibiré por el personal de TOGETHER S.A. será por correo electrónico. La empresa no se responsabilizara por atrasos y errores en los procesos si es que el estudiante no revisa su correo electrónico frecuentemente. SEPTIMO.- Declaro que TOGETHER S.A. no se hace responsable por los atrasos o procesos en general por parte de los aspirantes que no traigan a tiempo los documentos requeridos o no cancelen a tiempo sus obligaciones. OCTAVO.- Declaro y tengo conocimiento que en caso de retirarme ya sea en proceso de los trámites del programa o durante el viaje, TOGETHER S.A. no rembolsará los rubros cancelados hasta ese momento. NOVENO.- Declaro y acepto que los coordinadores y reclutadores Ecuatorianos no serán responsables de los estudiantes durante el viaje. El programa incluye la asistencia de un coordinador en los Estados Unidos. DECIMO.- Declaro y soy consciente que TOGETHER S.A. no se responsabiliza por las acciones o problemas legales en las que los aspirantes se puedan involucrar en Estados Unidos. Declaro que, he leído, entiendo todo lo de arriba detallado estoy completamente de acuerdo sin poder hacer reclamos futuros. Guayaquil, de 2.012 C.C. No. DECLARACION JURAMENTADA DE PRESTACION DE SERVICIOS TOGETHER S.A. Página 2 de 2

Dear : Welcome to the Work & Travel 2013 Program! It is a pleasure to have you as one of our participants; we are sure you will have the time of your life during your stay in the U.S. Enclosed you will find a list of documents that you will need to complete in order to fully register into the program: Application (including medical form) Registration form Legal Statement Also, you need to attach the following documents: Color copy of passport (data page, valid for at least 2 years) University Certificate of Enrollment 3 Visa Photos (5x5 cmts, white background) All this forms need to be completed and presented at TOGETHER offices in a folder no longer than September 15 th, 2012. Our coordinators are always willing to help you if you need any assistance; we will do our best to make your experience the greatest. Best, Fernando Gilbert J. Director

INTERNATIONAL HOSPITALITY STUDENT EXCHANGE Janus International Hospitality Student Exchange Work and Travel Application Janus International Hospitality Student Exchange Office 16102 Theme Park Way Doswell, Virginia 23047 Toll Free: 1-866-249-3888 Fax: 1-804-876-3113 E-mail: Marylou@janus-international.com PLACE PHOTO HERE Name of Representative: PERSONAL DATA (Put information as it appears on passport) Last Name First Name Middle Name Date of Birth (month/day/year): Male Female Married Single Children: Yes No Place of Birth (City): Country: Citizenship: Country of Permanent Legal Residency: *Please include a photocopy of Passport PERMANENT ADDRESS Number and Street Name City Postal Code Country Telephone Number (including the country code and area code) E-Mail Address of the Participant: WORK AND TRAVEL SITE INFORMATION Name of Work and Travel Site: Address: Dates Availability (month/day/year) Start: End: CONTACTS IN THE UNITED STATES Do you have a family member, relative or close friend in the United States? Yes No Number and Street Name City Postal Code Telephone Number

EMERGENCY CONTACT INFORMATION Name Relationship Address City Country Postal Code Telephone Number EDUCATIONAL BACKGROUND Are you currently enrolled as a student? Yes No Field of Study: Undergraduate Program Graduate Program *Please include Resume/CV and Introduction Letter Work and Travel History Have you ever participated in a Work and Travel Program in United States? Yes No If you answered Yes, please complete the following questions: When did you participate in the Work and Travel Program (month/date/year)? What is the name of the Host/Employer? What State? PROOF OF STUDENT STATUS *To be completed by the School Official Student Name: Name and Address of School: Major Field of Study: Student Participant s Expected Date of Graduation (month/date/year): This is to certify that is currently registered as a full time student in our school for this academic year. Name of the School Official: Title: Signature: Date: SCHOOL SEAL

MEDICAL INFORMATION *Must be completed by a Registered Physician in English Patient s Name: Height: in cm Weight: in kg Blood Pressure: Pulse: Please state the patient s overall health: Has the patient been afflicted or is currently afflicted of the following? If so, please provide detailed information regarding the patient s affliction. Yes No Yes No Chicken Pox Seizure Measles Frequent Cough Mumps Appendectomy Rheumatic Fever Diabetes Malaria Severe Migraine Hepatitis Speech Defect Goiter Asthma Allergies Others Has the patient been hospitalized for the past 5 years? Yes No Is the patient currently taking injections or medications? Yes No Has the patient been diagnosed with any illness or condition which requires regular medical attention? Yes No Please provide detailed information about the patient s affliction: Does the patient have allergies? Yes No If yes, what is the patient allergic to and what reactions is the patient developing?: Can these allergies be controlled by medications? Yes No Please state any restrictions of the patient during physical activities: *Medical Insurance provided by Janus International Student Exchange does not cover pre-existing conditions. The participant has been made aware of any possible pre-existing conditions for which they may need additional fees for the insurance coverage. Physician s name and put signature above Date Place of Examination

REFERENCE INFORMATION *To be completed by current or former employer, manager or teacher. Applicant s Name: Name of Reference: Title: Telephone Number: Relationship with the Applicant: How long have you known the applicant?: Do you think the applicant is qualified to participate in the Work and Travel Program? If yes, please justify the answer. INTERVIEW CONFIRMATION AND EVALUATION *To be completed and signed by one of the following: Janus International Hospitality Student Exchange Representative or Recruiting Organization Representative. I have discussed the rules and regulations of the Work and Travel Program in detail. I have also provided information about job openings and work sites available in this program. By signing, I certify that I have interviewed the participant and reviewed the participant s qualifications and experience. The participant has the required education, skills and experience to participate in the Work and Travel Program. Participant s Name: Interviewer s Name: Interviewer s Title: Organization: Date and Place of Interview: Method of Interview: Comments or assessment to the participant: Signature of the Interviewer:

JANUS INTERNATIONAL HOSPITALITY STUDENT EXCHANGE Agreement Terms for the Work and Travel Program To complete your application, please take the time to carefully read these terms and guidelines. If you agree to the conditions and statements outlined below, please put a check mark next to each item, then sign and date the bottom of this page before submitting. Ask questions if you do not understand any part. I will follow and obey all local, state and U.S. federal statutes, laws and Program Rules Janus may terminate my participation if my conduct or actions damage the J-1 Program I will honor my Job and Work and Travel Program Agreements, policies and terms If Janus withdraws my sponsorship, I will leave the U.S. and return home within 10 days If I remain in the U.S. illegally, I can be arrested, deported and denied future entry If I stay illegally, I understand that Janus is required by U.S. law to advise the U.S. Gov t I know that my full-time job, overtime, and a part-time job are not guaranteed by Janus I will cooperate with reasonable requests to change any inappropriate behavior Janus will be contacted by me if I have any problems or concerns during my U.S. stay For housing that has been arranged for me, I agree to monthly payments for at least 2 months If I violate housing rules and am evicted, I am still obligated for full 2 months payment If I cannot complete the W&T Program, for any reason, I must return to my country I will advise Janus of my arrival date and departure date from the U.S. My J-1 Visa cannot be converted or changed to another Visa type during my U.S. visit My Visa will be invalidated if I transfer from one Work and Travel Program to another It is likely that I will not earn enough $ in the U.S. to cover all of my program expenses It is my responsibility to ask questions on any terms or details that I do not understand I will arrange for someone to interpret this application for me if I cannot comprehend it I will bring enough $ with me to cover 2-4 weeks of food, housing and transportation I understand that my attendance at the Orientation Session is required for participation The Health Insurance included in my fees covers the arrival /departure dates indicated If I decide to extend my stay to the J-1 maximum, I need to advise Janus immediately I will need additional Health Insurance coverage for any extension of my stay Janus Health insurance does not cover any pre-existing health conditions from my past I have written down the phone numbers I need to call in case of emergency In a health or other emergency, I grant Janus the authority to act as my legal guardian I understand and authorize any necessary medical treatments not covered by insurance I grant Janus the authority to act on my behalf and without any liability if I am arrested To maintain my employment status, I accept the right of Janus to change my location If my actions result in my program cancellation, I will not be entitled to a refund of fees I am aware that the legal age for drinking alcohol in the U.S. is 21 I am aware that it is illegal for anyone to provide alcoholic drinks to those under age 21 It is unsafe for you to accept rides, gifts, housing, etc from people you do not know It is unwise to assume that other people will have your best interests and safety in mind I am aware that Janus International is not responsible for flight ticket changes in case I need to transfer to another location or if my job gets cancelled. By accepting participation in this Work and Travel Program, organized and directed by Janus International Hospitality Student Exchange LLC, also referred to as Janus, you agree to indemnify and hold Janus, its employees, directors, officers, agents, coordinators, job sites and support staff, harmless from any claim of liability for injury, damage, sickness, accident, delay including any expenses incurred by Janus, its employees, directors, officers, agents, coordinators, job sites and support staff, as it relates to your employment, that may arise due to strikes, economic conditions, war, quarantine, government restrictions, or regulations. Participant Name (print) Participant Signature Date

Work & Travel 2013 Ficha de Inscripción Fecha: Referencia: DIA MES AÑO FOTO Nombres: Apellidos: Fecha de Nacimiento Edad: No. Pasaporte o Cédula de identidad Dirección: Teléfono fijo: 0 4 2 Celular: Correo Electrónico: Universidad: Carrera: Semestre / Ciclo: Destino W&T: DIA MES AÑO Información adicional: ADJUNTAR A ESTA FICHA Fotocopia del pasaporte Prueba de Ingles Certificado de estudios Aplicación W&T Contrato W&T 3 fotos tamaño carné