Exchange Student Application Form

University of Illinois Springfield
Exchange Student Application Form

Name: Family ______________            First _______________              Middle ____________
Permanent Address: Street _______________________             City ________________
State/Province _________________ Country _______________ zip/postal code ______
Phone Number:

Email Address:

Country of Citizenship ____________________
Place of Birth (city/province/country) ________________________
Date of Birth (month/day/year) ____________________ Male _____ Female ______

Emergency Contact Information: Name _____________
Address: Street _______________________ City ________________
State/Province _________________ Country _______________ zip/postal code ______
Phone Number: Email Address:

Home institution
Charles Darwin University ____      Pierre-Mendes-France University Grenoble 2_____
Saitama University _____                University of Colima _____
University of Hull _____                  Queen’s University _____
Heilongjiang University _____         Roskilde University _____
Radboud University _____               University of Valencia _____
Sangmyung University _____          Vesalius College _____
IHECS _____

Major/Program of Study ______________ Semesters/Years completed ______________
Anticipated Graduate Date ______________
Undergraduate student ____ Graduate student ____

Which semester/year do you want to begin your exchange program?
Summer _____ Fall _____ Spring _____
Are you applying for one ____ or two_____ semesters?

Signature ________________________ Date __________________
You will also need to submit:
1) An official transcript of your university coursework
2) A letter from your home institution nominating you as an exchange student
3) A TOEFL test score or an equivalent test score if your first language is not English
4) A financial affidavit confirming sufficient funds for the term of study (not needed for on line exchange students). The approximate costs for room and board for one semester are $5000.
5) A photocopy of your passport