Semester You Plan to Enroll:

Fall (August-December): ________ (yyyy)

Spring (January-May): ________(yyyy)
Summer (June-July):
________(yyyy)

Application for International Student Admission

1. _______________________________________________________________________________________
Family Name

First Name

Middle Name

Date of Birth: (mm/dd/yyyy) ___ / ___ / ___

Gender: Male
Female
Country of Birth: ____________________________ Country of Citizenship: __________________________
E-mail: ___________________________________________________________________________________
2. U.S. Address (Required if currently in the United States)
Address: __________________________________________________________________________________
__________________________________________________________________________________
City: ____________________________________ State: ________________ Zip Code: __________________
Home Phone: _____________________________ Cell Phone: ______________________________________
3. Home Country Address (Required)
Address: __________________________________________________________________________________
__________________________________________________________________________________
City: ________________________________________ State/Province: _______________________________
Zip Code: ___________________________ Country: _____________________________________________
Home Phone: _____________________________ Cell Phone: ______________________________________
4. Major/Field of Study (Required) ____________________________________________________________
5. Dependent Information (Please print.) A dependent is defined as a spouse or child of an F-1 student.
*Information needed only for dependents traveling with F-1 student.
Family Name

First Name

Date of Birth Country of Birth

(mm/dd/yyyy)

Relationship to Student

6. Friend or relative who has permission to discuss your file or to pick up your I-20
Name: __________________________________ Relationship: (i.e., uncle, friend, etc.) __________________
Phone Number: _____________________________ E-mail: ________________________________________
7. Address if I-20 is to be mailed (College does not send documents via courier service.)
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
__________________________________________________________________________________
City: ________________________________________ State/Province: _______________________________
Zip Code: ___________________________ Country: _____________________________________________
8. Family member or emergency contact in home country
Name: __________________________________ Relationship: (i.e., uncle, friend, etc.) ___________________
Phone Number: _____________________________ E-mail: ________________________________________
Home Country Phone Number: ________________________________________________________________
Does this person speak English? Yes
No
If no, what language? _______________________
9. Are you currently in the U.S.? Yes
No
If yes, state your current immigration status (F1, J1, etc.) _______________, and enclose copies of your
immigration documents (I-94, I-20, I-797, etc.).
10. Have you ever attended a DCCCD school? Yes

No

11. Translations
Translators must read and sign the following:
Any document containing a foreign language shall be accompanied by a full English language translation
which the translator has acknowledged as complete and accurate and that he or she is competent to translate
from the foreign language into English.
___________________________________ ___________________________________ _______________
Translator Name (Printed)

Translators Signature

Date

IMPORTANT! Please read before signing.

Health Insurance is strongly recommended. Upon arrival, you may request a brochure with insurance policy
information from the Multicultural Center.
Permission for Emergency Treatment: In the event of an emergency illness, accident or injury I hereby grant
permission for the Brookhaven College staff to give first aid and/or to call an ambulance to have me
transported to a hospital at my expense.
___________________________________________________________
Students Signature

__________________________
Date