I.
REQUIRED INFORMATION You
must fill out all the information in this section. If you omit any required information,
the application will not be submitted.
0. Center you wish to attend:
Colorado School of Mines Indiana State University University of North Carolina G Valparaiso University
1.
Name: Your name must be spelled
exactly as it is on your passport. If possible, fax us a copy of your passport.
a Family Name First Name
2. E-Mail Address:
a Enter E-Mail Address Re-type E-Mail Address
3.
Address
(residence): Do
not leave any box blank. If there is no State or Province or no Postal Code, type
"none
aPO
Box or Street Number City State or Province Postal Code Country
4.
Mailing
Address:
If
your mailing address is the same as your residence, type "same" in the
box. If your mailing address is different, type your complete mailing address
in the box.
5. Telephone Number:
6. Country of Birth:
7. Country
of Citizenship:
8. Date
of Birth ( Day- Month-Year): Your date of birth must be the same as
on your passport.
a 1 2 3 4 5
6 7 8 9 10
11 12 13 14
15 16 17 18
19 20 21 22
23 24 25 26
27 28 29 30
31
b
January February
March April May June
July August September October
November December
c
1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
9. Gender:
Male Female
10. Marital
Status:
Single Married
11. If married, will your family accompany you?
Yes No
If
yes, complete Part III below.
12. Expected
start of INTERLINK studies:
a January March May June
August October
b
2010
2011
2012
II. ADDITIONAL INFORMATION Please answer all questions
below as accurately as possible to facilitate the application process.
13.
Fax
Number:
14.
How many weeks
do you expect to study at INTERLINK?
15.
What
do you plan to do after you study at INTERLINK?
Study
for BA/BS Study for MA/MS Study for PhD
Return home Travel in the US Other
16.
Where
did you first hear about INTERLINK?
Friend
Relative INTERLINK Student Fulbright
Office USIS Advertising Center INTERLINK Representative
Study Abroad Agency INTERLINK Advertisement
Internet Other
17.
Emergency
contact :
Name Address Telephone number
18. Highest
educational level completed:
Secondary University
19. Your
field of study (major):
20.
Standardized
English test:
TOEFL
TOEIC Michigan Other None
Name of test Score Date
[ Month/ Day/Year]
21.
Rank
your English ability: If you select Poor
or No Ability for any item, please submit a sample
of your writing with your application.
Very Good Good Fair Poor
No Ability Speaking
Very Good Good Fair
Poor No Ability Listening
Very Good Good Fair
Poor No Ability Reading
Very Good Good Fair Poor
No Ability Writing
22. Have
you studied in the US before?
Yes
No If yes, name of program Address
of program
23. Rank
housing options in order of your preference:
No Housing Assistance Needed University
Residence Hall Host Family Apartment First
Choice
No Housing Assistance
Needed University Residence Hall Host Family Apartment Second Choice
No Housing Assistance Needed University Residence Hall
Host Family Apartment Third
Choice
24.
Do
you have any physical disability or health problems that will require special
assistance?
No
Yes If yes, explain
25.
Who
will finance your education in the US?
Self
Family Government Other
If
other, please specify
26.
Do
you wish to receive your admission materials via express mail?
No
Yes
The charge for this service is $50.
III.
FAMILY MEMBERS If
family members will accompany you to the United States, you must provide information
for each one.
27.
Spouse: Information
must be exactly as it appears on passport.
Full Name
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Date
of Birth Country of Birth Country of Citizenship
28. Child
1: Information must be exactly
as it appears on passport.
Full
Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Date of Birth
Male Female Gender
Country
of Birth Country of Citizenship
29. Child
2: Information must be exactly
as it appears on passport.
Full
Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Date of Birth
Male Female Gender Country of Birth Country of Citizenship
30. Child
3: Information must be exactly
as it appears on passport.
Full Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Date of Birth
Male Female Gender Country of Birth Country of Citizenship
31.
Child
4: Information must be exactly
as it appears on passport.
Full
Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Date of Birth
Male Female Gender Country of Birth Country of Citizenship
AGREEMENT TERMS
I
understand the terms of my admission and agree to abide by the rules of the Center
and of the University. I, and / or my sponsor, will be fully responsible for the
cost of my studies while at INTERLINK . Further, I authorize release of
my credentials and of my medical records for medical and insurance purposes; I
also authorize treatment of any illness or injury by qualified health personnel
during my attendance at INTERLINK.
I AGREE:
Form will not be sent without agreement to terms