Mt. Hood Community College International Student Admissions Name:_ Email Address: Step 1 Step 2 Step 3 Submit the International Student Information Form o A Mt. Hood Community College ID number (needed for Step 2) will be emailed within 3 to 5 business days to the email address you provided. Take the College Placement Test and place into ENL094 or higher* o o Please see the Application Guide for more information on how and where to take your test *Students who place below ENL094 will not be eligible for admission to the College and therefore should not proceed to Step 3. Submit the following documents to apply as an international student at MHCC: International Student Financial Statement, Affidavit of Support, and official bank statement Measles vaccine certificate Tuberculosis clearance certificate For students applying within the U.S.: A copy of your visa, I-94 stamp and the ID page in your passport Transfer students: A transfer clearance form and a copy of your I-20 Official college transcripts (for students who are transferring from a U.S College or University) $50 non-refundable application fee Please send this completed checklist with your application packet. It is your responsibility to see that your application packet is complete before submitting it to the Admissions Office. An I-20 can only be issued once the student has completed the Mt. Hood Community College Placement Test with successful placement into college level courses, and all the application materials have been received. Please email application materials to: Janine.Shockley@mhcc.edu OR Mail to: International Admissions Mt. Hood Community College 26000 SE Stark St. Gresham, OR 97030 USA For more information contact: Janine Shockley Telephone: (503) 491-7165 Fax: (503) 491-7388 Email: Janine.Shockley@mhcc.edu
International Student Information Form Please type or print neatly in black or blue ink Mail, fax or email application materials to: Applying for (check one term): Fall Winter Spring Summer Year Year Year Year International Admissions Mt. Hood Community College 26000 SE Stark Street Gresham, OR 97030 Fax: 503-491-7388 Janine.Shockley@mhcc.edu How did you hear about Mt. Hood Community College? Brochure or advertisement Friend/Family Member Study Oregon website Phone book or newspaper Education Fair Other Student Information Applicant Name: (Please write your name with the same spelling that appears on your passport): Male Female Family Name Given Name Other Names of Birth (Month/Day/Year) Intended major/area of study Country of Birth Country of Citizenship US Mailing Address Permanent Address in Home Country Number and Street Number and Street City State or Province City State or Province Country Postal Code Country Postal Code Email Address Telephone Number Email Address Telephone Number Emergency Contact Information If you are dependent on your parents, please list a parent or legal guardian. If you are not dependent on your parents, list a relative or a friend who knows where you can be reached. Family Name Given Name Other Names Address Number and Street City State or Province Country Postal Code Telephone Number Visa Information Passport Expiration Have you ever applied for permanent residence? Yes No If you are now in the United States, what is your current visa status? (i.e. F-1, B-1/B-2) If F-1, what institution are you now attending? If on a tourist visa (B-1/B-2) what is your date of entry and expiration? (see I-94)
Education Information List all previous educational experience and indicate special diplomas or certificates Official Name of School Location s of Attendance Diploma, Certificates, Degrees Received From (Mo./Yr.) To (Mo./Yr.) Dependent Information Please complete the following section for each dependent you plan to bring with you. Attach another sheet if necessary. Dependent Name: (Please write dependent s full name with the same spelling that appears on his or her passport) Male Female Family Name Given Name Other Names Relationship to you of Birth (Month//Year) Country of Birth Country of Citizenship Visa Status Dependent Name: (Please write dependent s full name with the same spelling that appears on his or her passport) Male Female Family Name Given Name Other Names Relationship to you of Birth (Month//Year) Country of Birth Country of Citizenship Visa Status Release of Information to a Third Party or Sponsor I authorize the release of any information submitted by me in connection with my Mt. Hood Community College application for admission to any person, firm, corporation, association or government agency for the purposes of explanation or verification. This information includes but is not limited to: grades, attendance, number of credits registered for, and employment information. Student signature Verification of Application Information I certify that the information on this application form is true and correct. I have read and understand the MHCC guidelines and instructions regarding SEVIS. I know where to access current immigration regulations regarding F-1 student visa status. I understand if I am admitted to Mt. Hood Community College as an International Student, it is my responsibility to properly maintain my non-immigrant status and that I must complete 12 or more credits and maintain a minimum GPA of 2.0 each term in order to meet satisfactory academic progress and remain in status with the U.S. Citizenship and Immigration Services (CIS). Student signature
International Student Information Health Requirements Family Name First Name Address of Birth Age Sex M F Country of Birth Blood Type Measles Vaccine Requirement All entering students born after 1956 are required to have two doses of any combination of measles/rubella vaccine, or show evidence of immunity (immune titer) on or after December 1989. Please indicate your vaccination status below and attach official record on doctor s letterhead. Measles, Mumps, and Rubella Month/Year Month/Year or Measles and Rubella Month/Year Month/Year or Measles Vaccine Month/Year Month/Year or Immune Titer Month/Year Month/Year Tuberculosis Clearance Record It is required that any student born in a country not listed below be Mantoux skin tested and evaluated for communicable tuberculosis before being accepted to Mt. Hood Community College. Australia Great Britain Portugal Austria Greece Spain Belgium Ireland Sweden Canada Italy Switzerland Denmark Luxembourg The United States Finland New Zealand Germany Norway
International Student Tuberculin Test Record Tuberculin Test Given Read Type & Amount Reaction in MM* Physicians Signature *Measure in duration only. If reaction is 10MM or higher, student must have a chest x-ray. Please send the x-ray results on doctor s letterhead with this form. Health Insurance Verification Form Please check and sign one of the following: I have a health plan that will insure medical expenses during my stay in the United States. Company Name Company Address Policy Number Expiration I certify that this information is correct to the best of my knowledge, and may become a part of my financial responsibility statement. I understand that I must bring my insurance policy to the International Admissions Evaluator before registering for classes. Student Signature I do not have a health plan, but will subscribe to a program when I arrive in the U.S. Please send information regarding health insurance. Student Signature
Please list and document the funds available to you in each of the two years you expect to attend this college. Consider the exchange and currency regulations and report the funds in terms of U.S. dollars. Source Personal funds Required documents Official bank statement reflecting: current balance name of bank and account holder date the completed affidavit of support shown below $ Amount of Support Sponsor (Family or friend) Government or scholarship Same as above Official copy of award letter $ $ Total funds available (Must equal the estimated cost of attending as stated above) $ READ BEFORE SIGNING: By Submitting, I acknowledge I am legally obligated to pay all charges incurred by registering as outlined under the MHCC Billing Collection Rights and Responsibilities which can be found at www.mhcc.edu/billing. I am also responsible for understanding and following college policies, administrative regulations, and procedures. Charges may include late fees, reimbursement for agency collection fees, attorney fees, and Oregon Department of Revenue charges for the collection of all delinquent debts owed to the college. By not paying all charges at the time they are incurred, I acknowledge that this debt is considered education debt/loan and that the educational debt is non-dischargeable under Section 523 (a) (8) of the US Bankruptcy Code. There is no statute of limitation on the collection of educational debt. To have course tuition/fee charges removed, I must process a drop or withdrawal on MyMHCC or through the Admissions, Registration and Records office within the refund period. (Revised: 1-28-13) Affidavit of Support - To be completed by sponsor or applicant I hereby certify that I am able to and promise to pay the estimated cost of attending Mt. Hood Community College as stated above. I understand expenses for tuition, fees, books/supplies and cost of living are payable in U.S. dollars. Documentation of my financial resources in the form of an official bank statement and/or validated award letter accompanies this affidavit of support. Name Signature Relationship to applicant Sponsor s Address Certification of information provided I certify that all statements on this International Student Financial Statement and Affidavit of Support are true and accurate. All copies of documents that I have provided are unaltered and reflect true copies of originals. I understand that admission to or enrollment at Mt. Hood Community College may be denied if any information that I have provided is found to be false. I agree to notify MHCC of any changes in my financial circumstances. Applicant Signature (required)
Mt. Hood Community College International Student Transfer Form The purpose of this form is to determine eligibility for school transfer. An F-1 student who was not pursuing a full course of study at the school he or she was last authorized to attend is ineligible for school transfer and must apply for reinstatement. Please complete this form if you are transferring from a U.S. college or university. Name of Birth Term you plan to transfer Have you left all prior colleges or universities in good academic standing? Yes No If no, please explain: By signature I grant permission for the DSO from each school to share information regarding my academic records to assist me in my transfer process and maintaining status with CIS regulations. This permission is valid until I have completed my degree program. Student signature To be completed by your current international student advisor or DSO First term/year of student s enrollment at your school: Summer/ Fall/ Winter/ Spring/ Last term/year of full-time enrollment: Summer/ Fall/ Winter/ Spring/ Has this student ever been granted practical training? If yes, type and dates Yes No Has this student maintained legal status according to US immigration regulations? If no, please explain the circumstances Yes No Name of School Official Institution Name Email Title Phone Fax Address City State Zip Code Signature of School Official Please email, fax or mail this completed form and a copy of the student s I-20 to: Mt. Hood Community College Office of Admissions and Records 26000 SE Stark Street Gresham, OR 97030 Fax: (503-491-7388) Janine.Shockley@mhcc.edu