Studying Abroad or Going on Exchange

Applicant Information

Full Name

		Family Name				First Name			Middle Name
Date of Birth						Gender			☐ Male  ☐ Female
Country of Birth					Country of Citizenship
Permanent Address
(In home country)
		City	District or Providence			Country			Postal Code
Phone Number				Local Phone Number (US)
Local  Address
(In United States)
		City	State						Postal Code
Email Address
Marital Status		☐ Single  ☐ Married	If Married, Name of Spouse
Nationality:

How were you referred to United States

University?

Immigration and Visa Information

	Visa Type☐ F-1		☐ F-2	☐ No Visa   ☐ Other (Please explain)
	Will your Spouse or Dependents require an I-20? (List Dependent s and Passport
							☐ Yes   ☐ No
	Number)
	Name & Relationship				Passport Number
	Name & Relationship
					Passport Number
	Name & Relationship
					Passport Number
	Please attach Passports for all dependents
	Family Information
	Father’s Name					Occupation
	Address
	Mother’s Name					Occupation
	Address

Emergency Care (Who may we contact in case of emergency?)

Please print name and phone number of a contact person in your home country and/or in the U.S.

US Contact: (Required)	Name
	Phone
Home Country Contact:	Name
	Phone
			Adapted from  http://www.usuniversity.edu/international/International%20Student%20Admission%20Application.pdf

Start Session: _____________________

Select program of interest listed below:

Undergraduate Programs

·         Undergraduate programs are offered Fall I only

☐ Bachelor of Arts in Management                                        ☐ Bachelor of Science in Health Science

☐ General Management                                                                ☐ Health Education

☐ Entrepreneurship                                                                        ☐ Health Services Administration

☐ Human Resources                                                                       ☐ Gerontology

☐ Marketing

Graduate Programs- These are a twice a month weekend/hybrid schedule

_{☐ Master of Business Administration} ☐Master of Science in Health Science- Specialization in Health Care Administration

☐ Master of Arts in Education –Specialization in Higher Education Administration

Master of Arts in Education is offered Fall I only

English Proficiency

Is English your First Language? ☐ Yes ☐ No If No, what is your Native Language? How many years have you studied English in the past five years?

___________________________________

___________________________________

Health and Medical

NOTE: USU requires all international students to have health insurance for the duration of their program.

Do you currently have Health Insurance?

To the best of your knowledge are you now in good physical and mental health?

Personal Statement – explaining why you wish to study your chosen postgraduate course

Adapted from http://www.usuniversity.edu/international/International%20Student%20Admission%20Application.pdf

Education Background Information

Are you a high school (secondary) graduate?              ☐ Yes  ☐ No     If “Yes,” list date of graduation

In chronological order, list any secondary schools and colleges or universities that you have attended either in the U.S. or in another country. If you attended more than two schools, give the necessary information on a separate page. You must provide a diploma or other proof of graduation from a secondary school as well as copies of transcripts (with an English translation) from any college or university that you have attended. Originals will be validated when you report for orientation.

Secondary School Name                 

Location

Dates Attended

Major

Diploma/Degree Received

College Name

Location

Dates Attended

Major

Diploma/Degree Received

College Name

Location

Dates Attended

Major

Diploma/Degree Received

List any additional schools and colleges on a separate sheet if needed.

Professional Experience

List professional experience relevant to your program starting with the most recent first.

Employer

Location

Dates Employed

Job Title

Employer

Location

Dates Employed

Job Title

List any additional employers on a separate sheet if needed.

Adapted from http://www.usuniversity.edu/international/International%20Student%20Admission%20Application.pdf