page 1 of 2

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ClllClAL lnlC8MA1lCn LxAC1L? AS l1 ALA8S ln ASSC81
lamlly: _______________________ llrsL: ______________________ Mlddle: ___________________

uaLe of 8lrLh _____ /_____ / _____ CounLry or CounLrles
MonLh uay ?ear of ClLlzenshlp __________________________________________

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ermanenL Address ouLslde Lhe u.S. ____________________________________________________________
SLreeL
__________________________________________________________________________________________
ClLy SLaLe/rovlnce CounLry osLal Code
__________________________________________________________________________________________
1elephone L-Mall Address

ll lSSuLu, Auu8LSS 1C WPlCP ?Cu8 l-20 SPCuLu 8L MAlLLu, ll ulllL8Ln1 l8CM L8MAnLn1 Auu8LSS A8CvL.
noLe: You will be given an option to have your I-20 shipped via regular airmail, or pay for FedEx express shipping, at a later date.

1oday's uaLe _____ / _____ / _____ 1he followlng address ls valld unLll _____ / _____ / _____
MonLh uay ?ear MonLh uay ?ear
__________________________________________________________________________________________
SLreeL
__________________________________________________________________________________________
ClLy SLaLe/rovlnce CounLry osLal Code



A8L ?Cu Cu88Ln1L? ln 1PL uSA Wl1P A vlSA C1PL8 1PAn l-1? ll ?LS, vlSA 1?L ______________________

Check here lf you're currenLly aLLendlng or have aLLended anoLher SLvlS-approved school, or lf you are engaglng
ln or have compleLed CpLlcal racLlcal 1ralnlng (C1). ln order Lo malnLaln your currenL l-1 sLaLus, you musL ask
your school Lo release (Lransfer ouL) your SLvlS record Lo Chapman unlverslLy wlLhln 60 days of compleLlon of
your academlc program or C1. 1he Llme beLween Lhe Chapman unlverslLy program sLarL daLe and Lhe prevlous
program or C1 end daLe cannoL be 3 monLhs or more lf you wlsh Lo sLay ln Lhe uS durlng Lhe gap.


uaLe of anLlclpaLed Lransfer release ____ /____ /____ LxplraLlon daLe of l-1 vlsa ____ /____ /____
MonLh uay ?ear MonLh uay ?ear
1. Are you currenLly ln Lhe uSA? _____________________

2. lf yes, wlll you be Lravelllng ouLslde of Lhe uSA prlor Lo Lhe sLarL of Lerm aL Chapman? lf so:
When wlll you deparL Lhe uSA? __________________________


Check here lf you have dependenLs (spouse and/or chlldren) accompanylng you Lo Lhe u.S. Cn a separaLe sheeL
of paper, provlde each dependenL's passporL name, date of birth (mm/dd/yyyy), counLry of blrLh, clLlzenshlp and
relaLlonshlp Lo you.
Pareja Nicolas
07 08 1995
Bolivia
Colinas del Urubo Calle 10
Santa Cruz de la Sierra
Andres Ibanez Bolivia 00000
591 3703987 nicolas.pareja@hotmail.com
12 24 2013 05 01 2014
Calle Barcelona 1 Barrio Las Palmas
No
Santa Cruz de la Sierra
Andres Ibanez Bolivia 00000
This sheet must be completed in English including all signatures.
* hLLp://www.chapman.edu/sLudenLs/LulLlon-and-ald/sLudenL-buslness-servlces/lndex.aspx page 2 of 2
1nIS AGL IS kLUIkLD ICk I-1 S1UDLN1 VISA APLICAN1S.

SLC1lCn 1: 1PlS SLC1lCn MuS1 8L CCMLL1Lu 8? 1PL ALlCAn1.
lamlly: _______________________ llrsL: ______________________ Mlddle: ___________________

?ou musL enLer Lhe amounL ln U.S. do||ars avallable for your supporL from each source. 1he LoLal amounL of flnanclal supporL
you llsL on Lhls page should be equal to at least the total educational and living costs for one year. Please refer to the Chapman
unlverslLy 8uslness Cfflce for LulLlon and on-campus llvlng expenses*. 1here should also be evldence of enough Lo cover oLher
mlscellaneous cosLs, such as books and healLh lnsurance, amounLlng Lo abouL $2,700.

L8SCnAL lunuS $
lAMlL? SCnSC8 $
C1PL8 SCnSC8 $
LCAn l8CM: $
SCPCLA8SPl l8CM: $
1C1AL IINANCIAL SUCk1 AVAILA8LL 5

A11ACn CIIICIAL DCCUMLN1Ak LVIDLNCL CI IINANICAL SUCk1 Ck nAVL AN CIIICIAL CCMLL1L SLC1ICN 3. LLASL
WkI1L CUk NAML & ID NUM8Lk CN AN SULLMLN1AL DCCUMLN1S.

l cerLlfy LhaL Lhese funds are adequaLe Lo cover all esLlmaLed school and llvlng expenses, lncludlng Lravel Lo and from Lhe u.S.

SlgnaLure of AppllcanL: ___________________________________ uaLe: _________________


SLC1lCn 2: 1PlS SLC1lCn MuS1 8L CCMLL1Lu 8? An? L8SCnS LlS1Lu AS lAMlL?" C8 C1PL8" SCnSC8.

name of Sponsor (prlnL):__________________________ 8elaLlonshlp Lo AppllcanL: ______________________

Address of Sponsor: _________________________________________________________________________
SLreeL
__________________________________________________________________________________________
ClLy SLaLe/rovlnce CounLry osLal Code


l cerLlfy LhaL l wlll provlde Lhe funds sLaLed above Lo Lhe appllcanL for Lhe purpose of full-Llme sLudy aL Chapman unlverslLy.

SlgnaLure of Sponsor: _______________________ uaLe: _________________ hone: __________________


SLC1lCn 3: 1PlS SLC1lCn MuS1 8L CCMLL1Lu 8? 1PL ClllCL8 Cl 1PL 8Ank C8 llnAnClAL lnS1l1u1lCn.
Check here lf you wlll subsLlLuLe a documenL from a bank and/or flnanclal lnsLlLuLlon for Lhls secLlon.

1hls ls Lo cerLlfy LhaL __________________________ has funds necessary Lo meeL Lhe educaLlonal and llvlng expenses llsLed
above. 1hls cerLlflcaLe does noL consLlLuLe a sLaLemenL of llablllLy on my parL, or Lhe flrm, bank, or lnsLlLuLlon LhaL l represenL.

name of Cfflcer: ____________________________1lLle: _____________________

name of lnsLlLuLlon: ___________________________________________________

Address of Lhe CrganlzaLlon: ____________________________________________
_________________________________________ hone: ___________________

SlgnaLure of Cfflcer: _______________________ uaLe: _____________________
8equlred: organlzaLlonal seal or sLamp here
Pareja Nicolas
65,000
65,000
12/24/2013
Father
Colinas del Urubo Calle 10
Santa Cruz de la Sierra
Andres Ibanez Bolivia 00000
12/24/2013 591 3703987
This sheet must be completed in English including all signatures.
Please submit both pages to the Office of Admission electronically to intladmit@chapman.edu or via fax (714) 628-3404.