APPLICATION FORM CALIFORNIA STATE UNIVERSITY, FULLERTON

Transcription

1 APPLICATION FORM CALIFORNIA STATE UNIVERSITY, FULLERTON PROGRAM SELECTION Study Abroad: Spring Fall Year: Are you applying for one or two study abroad semesters? STUDENT INFORMATION Applicant Information (as it appears on passport) First Name: Last Name: Student Country of Birth: Country of Citizenship: Native Language: (bitte angeben!) Date of Birth: Month: Day: Year: Gender: Male Female Marital Status:: Single Married Will your Children accompany you to the U.S.? t coming with me to the U.S. I don t have children. Student s Permanent Address in Home Country Address (Street Name/Number): City: Page 1 of 5

2 State/ Province: Zip/Postal Code: Country: International phone number: High School Name of High School: Address: State/ Province: City: Postal Code: Attendance Dates (Month/Year): From: Until: EDUCATION HISTORY Name of current University What is your major? If you have taken TOEFL, IELTS or DAAD, please enter the score: Are you currently attending a college or university in your home country? Are you currently in the United States? Are you a permanent resident of the U.S., (do you own a Green Card) or U.S. citizen? Page 2 of 5

3 Are you transferring from another school in the United States? INFORMATION RELEASE Information about your application can be released to the following person: Name: Relationship: Julia Fischer (IEC Online GmbH) Agent FINANCIAL SUPPORT Source of financial support: Scholarship Parent/Family Member (please include affidavit) Sponsor (please include affidavit) Personal Savings I have read and agree to the University Semester Abroad refund policy ( as stated on the website. I certify that the above information is true and correct. te: The refund policy is subject to change at any time APPLICATION FEE All applicants must pay the non-refundable application fee. Your application will not be processed without your signature and application fee. Method of Payment Credit Card (recommended payment option) Page 3 of 5

4 Please choose one of the following: Visa MasterCard Other: Total amount to be charged in USD $: Card Number: Expiration date (month/year): CVV2: Cardholder s name: Billing Address (Street): Billing Address (City and Zip Code): Billing Address (Country) Cardholder s relationship to Student: Cardholder s Signature: By signing above, I authorize California State University, Fullerton to charge my credit card for the amount I have entered above. CERTIFICATION All applicants must sign below. I certify that the information I have provided on this application is complete and accurate. I understand that failure to disclose correct information may result in the cancellation of my application or admission. Important Reminder: Only complete applications will be reviewed. Student Signature: City, date (mm/dd/yyyy): Page 4 of 5

5 Authorization for IEC to process the application I hereby permit International Education Centre (IEC Online GmbH) to submit the information which I have provided on the Application Form of the California State University, Fullerton via an electronic online application form created and maintained by the California State University, Fullerton. Student Signature: City, date (mm/dd/yyyy): Please submit your application with all required documents to IEC: IEC Online GmbH Marienstrasse 19/20 D Berlin Germany Page 5 of 5