Paper - Center for International Education | SIU

CENTER FOR INTERNATIONAL EDUCATION
INTERNATIONAL ADMISSIONS
Mail Code 4333
Southern Illinois University Carbondale
860 Lincoln Drive
Carbondale, IL 62901-4333
UNDERGRADUATE ADMISSION APPLICATION
(International Students) 2015-2016 Academic Year
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK
Return this form, official copies of your academic records, financial statement, test scores, and copy of your passport to International
Admissions. Your application fee of $40.00 by check, draft or money order is payable to Southern Illinois University Carbondale.
When you contact our office, please refer to your last name as printed below.
1. Please select your level and program (please refer to www.cie.siu.edu for a list of available programs):
o Only Intensive English Program (language)
o Conditional admission (with Intensive English) to a bachelor's degree in
_________________________________________
o Undergraduate studies: bachelor’s degree in _____________________________________________________________________
o Distance Education - Online Courses and Programs ________________________________________________________________
o Other (certificate, internship, exchange programs, etc.) in _ __________________________________________________________
2. Please select your start term (month and year):
INTENSIVE ENGLISH PROGRAM:
o No Intensive English Necessary
FALL 2015
o August 17 - October 09, 2015
o October 12 - December 11, 2015
SUMMER 2016
o June 13 - August 05, 2015
SPRING 2016
o January 19 - March 11, 2016
o March 23 - May 13, 2015
3. Have you attended a university or post-secondary institution of higher education?
4. Are you currently enrolled in SIU CESL?
o Yes o No
5. Have you previously attended SIU?
o Yes o No
o Yes o No
6. If yes, when were you last enrolled? (year) __________________________
Full Legal Name Family or surname as stated on your passport; if you have only one name, enter that name on the last or family name or Family name:
___________ ____________________________________________ ___________________________________ ___________________
Salutation
Last, Surname, or Family Name
First or Given Name
Middle Name
_______________________________ _________________ ________________________ Citizenship: Are you a citizen
of United States?
Date of Birth: (MM/DD/YYYY)
Gender
City of Birth
o Yes o No
________________________________________________________ _________________________________________________________
If no, Country of Citizenship:
Country of Legal Residence:
Permanent Home (non U.S.) Street Address: (If a USA address, do not use a PO Box Number)
______________________________________________________ ________________________________________________________________________
Number and Street
City
______________________________________________________ _______________ _______________________________________________________
State/Province/Prefecture
Postal Code
Country
Telephone Number (with codes):
_____________________ ___________________________ ________________________________ _________________________________________
Country Code
City/Area Code
Telephone Number
E-mail Address
Immigration Status:
Are you a permanent resident of the United States? o Yes o No
Do you currently have a U.S. Visa?
o Yes o No o Other
If YES, what type?
o Student F-1 Visa o Exchange J-1 Visa o Visitor B-1/2 Visa o Other
Have you applied for Lawful Permanent Residency of the United States (LPR, PR, “Green Card”) o Yes o No
If YES, provide your alien Registration Number
Include a copy of the front and back of your card with this application.
List below in chronological order, with dates, every school you have attended from the time you entered school to the present,
including U.S. schools if applicable and SIUC if applying to re-admission. List the certificates or diplomas you have earned or will
earn. You must submit an official mark sheet for your records and college transcripts/mark sheets become the property of SIUC. If
more space is needed, attach a separate sheet listing the additional institutions attended. In addition, please submit a sperate listing
of any college or university courses in which you are currently enrolled.
Dates of Attendance
To
From
Name and address of institutions
Primary Institution
Month/Year
MM/YYYY
Month/Year
MM/YYYY
Certificates/
Diplomas/
degrees earned
or to be earned
Date received or
to be received
Age when
received
Primary Institution Address
Secondary Institution
Secondary Institution Address
College/University
College/University Address
College/University
College/University Address
Has a member of your family graduated from SIUC? o Yes o No
If YES, please provide the following information about that family member
Full Name_ _____________________________________ Relationship_____________________________________
Degree_________________________________________ Year of Graduation________________________________
Signatures
Signature_______________________________________________________ Date_ _________________________
Public Safety Questions
Southern Illinois University Carbondale is committed to maintaining a safe environment for our students.
Answering “Yes” to any of the following questions will not automatically prevent admission. All applications are reviewed.
Have you pled guilty or no contest to, or been convicted of a felony?
o Yes o No
Have you ever been expelled, dismissed, placed, placed on probation or suspension,
or subjected to any other disciplinary sanction from
o Yes o No
Have you ever pled guilty or not contest to, or been convicted of any crime involving a felony,
violence, or the threat of violence?
o Yes o No
If you answered “Yes” to any of the questions above, please do the following:
– Send an explanation of the circumstances, including your name and date of birth
– Request that the Circuit Clerk of the Court (s) in which the order of conviction was entered send a copy of your records
– Send, or have the court send, these items to:
Enrollment Management
Attention: Campus Violence Prevention
Mail Code 4713
Southern Illinois University Carbondale
901 South Normal Avenue
Carbondale, Illinois 62901
In order for this application to be complete, you must sign the statement below and enclose the $40 application fee.
I certify that he statements made on this application are correct and complete including a report of all possible collegiate credit and criminal
history as described above. I understand that withholding information requested on the application or giving false information may make me
ineligible for admission to SIUC or subject to dismissal. I agree to maintain an accurate mailing and electronic address to which my statement of
account can be mailed and to make payment of all due amounts by published deadlines. If my account becomes delinquent, I understand that my
account may be placed with a collection agency and could be subject to litigation, and I agree to pay all associated costs. Further, I understand
and agree that my unpaid tuition and receivables account is considered an extension of credit and creates a loan due the university. I authorize
SIUC to maintain all my records under my legal name and understand these records and credentials in support of my application are property of
my application are property of SIUC and will not be returned or reproduced. I give Public Safety questions on the application.
Signature_________________________________________________________________________ Date____________________________