Download an Application Form - College of Extended Learning

International Extension Programs
California State University, San Bernardino
Application for Enrollment
International Extension
Programs
(Please print clearly or type)
For faster response, we recommend you fill out the application online at http://cel.csusb.edu/international/americanCultureLanguage/application.html
Name____________________________________________________________________________________________________________________________
LAST NAME (FAMILY NAME)
FIRST NAME
MIDDLE NAME
Home Country Permanent Mailing Address ____________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Telephone____________________________Fax____________________________E-mail __________________________________________________________
Date of Birth_________________________Country of Birth_________________________Country of Citizenship ______________________________________________
MONTH / DAY / YEAR
n Married n Single
Do you intend to bring your spouse ( n Male n Female ) or children with you? n Yes n No
Sex:
n Male n Female
Marital Status:
If yes, please list name(s), date of birth, place of birth, country of citizenship and relationship to student ________________________________________________________________
______________________________________________________________________________________________________________________________
n Yes n No
Are you transferring from another U.S. school?
If yes, name and phone # of school __________________________________________________________________________________________________________
Which quarter do you plan to begin the program? (Check appropriate box and specify the year.)
n Fall 20_____
n Winter 20_____
n Spring 20_____
n Summer 20_____
(Application deadline: September 1)
(Application deadline: December 1)
(Application deadline: March 15)
Application deadline: June 1)
Program(s) for which you are applying: (See brochure for exact dates and fees.) (Check appropriate boxes.)
n English Language Program (10 weeks)
n Graduate School/MBA Preparation Program—Level 6 (attach TOEFL or IELTS score)
n Study Abroad in the USA (degree credit) (attach TOEFL or IELTS score)
Are you applying for Conditional Admission? n Yes n No
If you are in the U.S., what type of visa do you now have? _____________________________Expiration date ________________________________________________
If you are outside the U.S., do you need a student visa?
Do you need housing assistance?
n Yes n No
n Yes n No (If yes, please fill out I-20 Application Form on reverse side.)
n Yes n No (Forms can be found at http://cel.csusb.edu/international/internationalStudentServices/housingOptions/homestayProg.html) ($120 placement fee)
Dormitory n Yes n No (Forms can be found at http://housing.csusb.edu/int_applications.html)
I will arrange my own housing. n Yes n No
Homestay
Person in the United States or agent representative who we may contact concerning your arrival:
Name________________________________________________________________________________________________________________________
U.S. Mailing Address ______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Telephone____________________________________________E-mail: ____________________________________________________________________
All applications must be accompanied by a U.S. check or international bank draft (non-refundable) for the current application fee amount (see brochure insert), made payable to “California State University, San Bernardino.” Scholarship students must submit a letter of verification from their sponsoring agency along with their application. See dates and fees insert for more information. For a faster response, we recommend you fill out the application online.
Mail completed application along with application fee (see Dates and Fees flyer), I-20 application (if required), affidavit of support, housing assistance fee (if applicable), TOEFL score or equivalent (if required) and copy of passport(s) to:
International Extension Programs • College of Extended Learning
California State University, San Bernardino
5500 University Parkway, Room SH–134 • San Bernardino, CA 92407-2393 U.S.A.
Telephone (909) 537-5978 • FAX (909) 537-5905 • E-mail: [email protected] • Website: http://global.csusb.edu
3207 Rev. 131204
International Extension Programs
California State University, San Bernardino
International Extension
Programs
Application for I-20 (Student Visa)
(Please print clearly or type)
If you plan to enter the United States on a student visa (F-1) from the International Extension Programs (IEP), please provide the following information:
You are required to certify that you possess sufficient funds to cover fees, local transportation and living expenses for each term of study in the International Extension Programs or for the Summer Study
in USA program. (See the Dates and Fees flyer for current required amounts.) For a married applicant who plans to bring spouse and/or children, a larger amount must be certified. You must include a
verification of financial support (a letter from your bank or a verification of scholarship or a sponsor’s statement of support) along with the application form.
How many terms (10-week periods) will you attend the English Language Program (ELP)? ____________________________________________________________________
How will you provide for your expenses while enrolled in the ELP?
n Personal Savings n Family and/or Friend n Other ______________________________________________________________________________
If you will be supported by personal savings, please indicate the total amount available to you: $ ________________________________________________________________
If you will be supported by a source other than a scholarship or personal savings, please provide the following information:
Sponsor’s name ______________________________________________________________________ Relationship to applicant ____________________________
Occupation ________________________________________________________________________ Total amount available to student $ ____________________
Address ______________________________________________________________________________________________________________________
__________________________________________________________________ Country __________________________________________________
Please have the person above complete the following statement:
“I guarantee that the funds described herein will be available to______________________________________________________________________________________
APPLICANT’S NAME
during his or her entire period of study in the English Language Program.”
Date______________________Signature of Sponsor ______________________________________________________________________________________
AFFIDAVIT OF SUPPORT
California State University, San Bernardino and the English Language Program (ELP) require verification that either the applicant or sponsor has adequate funds in the bank. Please have a bank official from
applicant’s bank or sponsor’s bank complete the following statement or enclose a separate letter on official bank stationery. (This section is not required for scholarship students.)
“I certify that the above statement of financial support is true and accurate, to the best of my knowledge, and that the private sponsor (applicant, relative or friend) named above is financially capable of meeting
his or her commitment and is permitted to do so under present regulations.” (Official bank seal is required.)
Date________________Signature of Bank Official ________________________________________________________________________________________
Bank Official’s Title ________________________________________________________________________________________________________________
Address of Bank ________________________________________________________________________________________________________________
NUMBER & STREET
CITY
__________________________________________________________________________________________________________________________
STATE
COUNTRY
ZIP
Please indicate where the I-20 Form should be mailed:
Name________________________________________________________________________________________________________________________
Telephone ____________________________________________________________________________________________________________________
Address ______________________________________________________________________________________________________________________
NUMBER & STREET
CITY
__________________________________________________________________________________________________________________________
STATE
COUNTRY
ZIP
Scholarship students: You must submit a letter of verification from your sponsoring agency along with the Application for Enrollment form. Applicant should sign the statement below after reading
it carefully:
“I certify the statements on the application form and the certified financial statement are correct and understand that inclusion of any false information is cause for dismissal from the English Language Program.”
Date______________________Signature of Applicant ____________________________________________________________________________________
International Extension Programs • College of Extended Learning
California State University, San Bernardino
5500 University Parkway, Room SH–134 • San Bernardino, CA 92407-2393 U.S.A.
Telephone (909) 537-5978 • FAX (909) 537-5905 • E-mail: [email protected] • Website: http://global.csusb.edu
3207 Rev. 131204

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