INTERNATIONAL EXCHANGE STUDENT APPLICATION

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1 Office of Global Studies and Study Abroad PO Box 10078, Beaumont, TX Telephone: 409/ Fax: 409/ INTERNATIONAL EXCHANGE STUDENT APPLICATION I,, understand that this International Exchange Student Application is for the purpose of studying at Lamar University as an exchange student and will not be considered for admission to any degree-awarding program at Lamar University. Student s Signature: Date (mm/dd/yyyy): Home University: (Name) (City) (Country) Semester(s) of Study at Lamar University: [ ] Fall (August-December) 201_ (check as many as applied) [ ] Spring (January-May) 201_ [ ] Summer (June-August) 201_ Academic Major at Lamar University: ( PART I STUDENT S INFORMATION (Please provide information as it appears in your passport) Student s Name: (Family) (First) (Middle) Birth Date (mm/dd/yyyy): Gender: Male [ ] Female [ ] Birth Country: Native Language: Citizenship Country: Address: Permanent Address: (in your home country) (House/Apt. Number and Street) (Town or City) (State/Province) (Country) (Zip/Postal Code) Page 1 of 10

2 Current Address: (in your home country, if different from above) (House/Apt. Number and Street) (Town or City) (State/Province) (Country) (Zip/Postal Code) Phone Number(s): (in your home country, including area and/or country code) Emergency Contact Information: (Please list name of preferred emergency contacts (someone the Office of Study Abroad can contact if you are in any kind of emergency) Contact 1 Contact 2 Family name, Given name Relationship Phone number (incl. area & country code) address Do you currently have an F-1 student visa or J-1 student visa from a U.S. institution? *If no, skip to PART II *If yes, please answer the following questions and submit documents required: [ ] Yes [ ] No Name of institution which issued the I-20 or DS 2019: Level of study: [ ] ESL Language Training [ ] High School [ ] Associate [ ] Bachelor [ ] Master [ ] Doctor [ ] Other: Expiration Date on I-20 or DS-2019: Visa Expiration: I-94 Admission Number: Date of entry into U.S.: *A Student Status Transfer Form provided by Lamar University must be completed by you and your current International Student Advisor. A copy of your current I-20 or DS-2019, student visa, and I-94 are also required. All documents must be mailed to the Office of Global Studies and Study Abroad at above address. Page 2 of 10

3 PART II - DEPENDENT INFORMATION Do you plan to include any dependents on your SEVIS I-20 or DS-2019 issued from LU? [ ] Yes [ ] No *If no dependents, skip to Part III *If your dependents will be accompanying you, or arrive separately, to the United States, an original financial document must be submitted with your application. If your government or other source is your financial guarantee, the document must state if they will be responsible for your dependents inside the US (travel, living expenses, and health insurance). All international students, and their dependents upon arrival, are required to be covered by the Lamar University Student Health Insurance program for duration of stay. Family name, Given name Birth Date (mm/dd/yyyy) Birth City Birth Country Country of Citizenship Country of legal permanent residence address (if age is 18 or older) *Please use additional page if needed for more dependents PART III - PREVIOUS EDUCATION/TEST SCORES Dependent 1 Dependent 2 Name of the high school you graduated from (in your home country): Date of your high school graduation (mm/dd/yyyy): Have you earned your Bachelor s degree? Yes No If Yes, which school did you receive your degree from? Have you ever attended any colleges or universities in the US? Yes No Which schools have you attended in the US? Have you ever taken the TOEFL or IELTS exam before? Yes No If Yes, attach a copy of your complete score report(s) to the back of this packet Page 3 of 10

4 PART IV - STUDY ABROAD PROGRAMS HOUSING REQUEST FORM Student s Name: (Family Name) (First) (Middle) Birth Date (mm/dd/yyyy): Gender: Male [ ] Female [ ] Semester(s) of Study at Lamar University: [ ] Fall (August-December) 201_ (check as many as applied) [ ] Spring (January-May) 201_ [ ] Summer (June-August) 201_ I wish to request assistance with on-campus accommodations. (Note: On campus housing is limited, early application is strongly recommended.) I will find my own housing accommodations. Student s Signature: Date (mm/dd/yyyy): Page 4 of 10

5 PART V - HEALTH INFORMATION Student s Name: (Family Name) (First) (Middle) Birth Date (mm/dd/yyyy): Gender: Male [ ] Female [ ] Home University: (Name) (City) (Country) Semester(s) of Study at Lamar University: [ ] Fall (August-December) 201_ (check as many as applied) [ ] Spring (January-May) 201_ [ ] Summer (June-August) 201_ The purpose of this form is to help Lamar University to be of maximum assistance during your study abroad experience. Mild physical or psychological disorders can become exacerbated with the stresses of life while studying abroad. It is important that the program be made aware of any medical or emotional problems you have experienced. The information provided will remain confidential and will be shared with program staff, faculty or appropriate professionals only if necessary to your well-being. Lamar University may not be able to accommodate all individual needs or circumstances. This information does not affect your admission into the program. Yes No 1. Are you generally in good physical condition (If no please attach explanation) Yes No 2. Have you ever been treated or are you currently being treated for any psychological or emotional problems? (If yes please attach explanation) Yes No 3. Do you have any allergies? (If yes please attach explanation) Yes No 4. Are you taking any medications? (If yes please attach explanation) Yes No 5. Have you had major injuries, diseases or ailments in the past five years? (If yes please attach explanation) Yes No 6. Are you a vegetarian or are you on a restricted diet? (If yes please attach explanation) Yes No 7. Is there any additional information (concerning medical conditions or physical disabilities) that would be helpful for the program to be aware of during your study abroad experience? (If yes please attach explanation) Name and telephone number of physician: Page 5 of 10

6 I certify that all responses made on this health information are true and accurate, and I will notify Lamar University Office of Global Studies and Study Abroad hereafter of any relevant changes in my health that occur prior to the start of the program. Student s Signature: Date (mm/dd/yyyy): Parent/Guardian s Signature: Date (mm/dd/yyyy): (if student is under 18) Parent/Guardian s Name & Contact Number: In the event of an emergency, illness or injury affecting (my son, my daughter, my ward, or myself), (student s name), born (date), the undersigned hereby authorizes immediate hospitalization and treatment recommended by and carried out under the supervision of a qualified physician, including administering anesthetic and performing necessary surgery. Known allergies to medications: Students blood Type, if known: Student s Signature: Date (mm/dd/yyyy): Parent/Guardian s Signature: Date (mm/dd/yyyy): (if student is under 18) Parent/Guardian s Name & Contact Number: PART VI APPROVAL AT YOUR HOME INSTITUTION Your home university must stamp your application form to confirm that they accept you undertaking an exchange with Lamar University. Your Home University Stamp Name: Title: Signature: Page 6 of 10 Date:

7 PART VII - FINANCIAL GUARANTEE & AFFIDAVIT OF SUPPORT *Estimated Expense Chart: these estimated tuition and fees are subject to change without prior notice. *For Undergraduate Exchange Students: Exchange Length Fall & Spring (12 hours per semester) Living Expenses, Health Insurance, Textbooks, other supplies Total funding to be required Exchange student One semester exchange Tuition/Fees Exempt $5,378 $5,378 Two-semester exchange (Fall to Spring, 9 months) Two semester exchange (Spring to Fall,12 months) Tuition/Fees Exempt $10,756 $10,756 Tuition/Fees Exempt $12,374 $12,374 *For Undergraduate Fee-Paying Visiting Students (with $1,000 scholarship & out-of-state tuition waiver): Program Length Tuition/Fees (12 hours per semester) Living Expenses, Health Insurance, Textbooks, other supplies Total funding to be required Visiting student One semester program (Fall or Spring, 4.5 months) Two-semester program (Fall to Spring, 9 months) Two-semester program (Spring to Fall, 12 months) $3,000 $5,378 $8,378 $7,000 $10,756 $17,756 $7,000 $12,374 $19,374 The United States Citizenship and Immigration Services (USCIS) require international students to submit proof of sufficient funds to finance their tuition and living expenses for the duration of their studies. Lamar University requires that this form be completed and submitted by the student, as well as the student s financial sponsor, prior to issuing form I-20 or Form DS Completion of this form does not imply admission or acceptance. *Instructions: If NO Seal or Stamp of Endorsing Bank directly (page 8, bottom left), a bank statement printed on official bank letterhead with a bank official s signature must accompany this document. The content should be in English and the available funds must be in converted in U.S. dollars. Page 7 of 10

8 * Statement of Student: Student s Name: Family Name First Name Middle Birth Date (mm/dd/yyyy): Gender: Male [ ] Female [ ] Home University: Semester(s) of Study at Lamar University: [ ] Fall (August-December) 201_ (check as many as applied) [ ] Spring (January-May) 201_ [ ] Summer (June-August) 201_ I, (student s name), certify that all information provided on this affidavit, along with the attached supporting documents, is correct and complete. I understand that F-1 and J-1 students are not eligible for U.S. government-funded financial aid or to work off-campus in the U.S. without first obtaining official authorization. Student s Signature: Date (mm/dd/yyyy): *Statement of Sponsor: (To be completed by the person who will financially support your educational, living, health and person expenses while at Lamar University.) I, (sponsor s name), certify that I will provide sufficient funds to pay for all educational and living expenses of the above named student. I also certify that I have $ in funds available to sponsor this student during his/her academic education at Lamar University. I certify that the student will not become a public charge during his/her stay in the United States. I am aware that this estimate of expenses is subject to change without prior notice and, as the financial sponsor of this student, that a minimum annual increase of 3% per year in total expenses should be considered. I certify that all information provided on this affidavit, along with my attached supporting documents, is correct and complete. Sponsor s Name: Relationship to Student: [ ] Family [ ] Friend [ ] Employer [ ] Other Seal or Stamp of Endorsing Bank Sponsor s Signature Date Signature of Bank Representative Date Page 8 of 10

9 PART VIII - CERTIFICATION OF INFORMATION All students must read and sign this section. By checking the box next to the statement you are agreeing to the terms and conditions laid out in the statement. If you do not check the box next to the statement, you will not be allowed to complete or submit this application. Notification of Rights under Texas Law: Information collected about you through this application may be held by any institution of higher education to which you apply. With few exceptions, you are entitled on your request to be informed about the collected information. Under Sections and of the Texas Government Code, you are entitled to receive and review the information. Under section of the Texas Government Code, you are entitled to correct in formation held by an institution that is incorrect. You may correct information held by any institution to which you apply by contacting the institution. The information that is collected about you will be retained and maintained as required by Texas records retention laws (Section et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time. If my application is accepted, I agree to abide by the policies, rules and regulations at any college to which I am admitted. I authorize the college to verify the information I have provided. I certify that the information I have provided is complete and correct and I understand that the submission of false information is grounds for rejection of my application, withdrawal of any offer of acceptance, cancellation of enrollment and/or appropriate disciplinary action. I understand that officials of my college will use the information submitted on this form to determine my status for residency eligibility. I authorize the college to electronically access my records regarding the Texas Success Initiative. I agree to notify the proper officials of the institution of any changes in the information provided. Texas Senate Bill 1107 requires that all new students under age 22 who attend on-campus classes at an institution of higher learning either receive a vaccination against bacterial meningitis or meet certain criteria for declining such a vaccination before the first day of the semester. The law states that students who do not qualify for an exemption must be immunized no later than 10 days prior to the first class day. This vaccination is valid for a five-year period. A student is NOT required to submit evidence of receiving the vaccination against bacterial meningitis if the student is 22 years of age or older by the first day of the start of the semester. Student s Signature: Date (mm/dd/yyyy): Page 9 of 10

10 APPLICATION CHECK LIST You must attach the following documents to this application: Passport (photocopy, biographical pages only) Bank Statement - Please attach a letter from your bank or other financial institution to the end of this packet, showing access to funds equal to or greater than the amount required by Lamar University Financial Requirements. (If in currency other than US dollars, please provide conversion rates and amounts.) Transcript - Please attach a copy of your most recent academic records to the end of this packet (with its translation in English). Language Proficiency Scores - Please attach a copy of your language proficiency scores (unless you are exempt) to the end of this packet. Essay of Educational Intent Please attach a short statement (no more than 500 words) explaining why you chose to study at Lamar University on exchange. Include a course preference list selected from Page 10 of 10

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