Application for I-20

San Jacinto College ID Number or U.S. Social Security Number:________________

Gender: MALE___ FEMALE ___

Name (in passport) _______________________________________________________________ Date of Birth: _________

LAST FIRST MIDDLE INITIAL MM / DD / YYYY

Country of Birth: ____________________ Country of Citizenship: _____________________Native Language:_______________

Permanent Physical Address In Home Country: (No P.O.Box accepted)

Street Address ____________________________________________________________City________________________________

Province/Territory_________________________ Country______________________ Postal/Zip Code ______________________

Home Phone Number (with country and city code): _________________________ Cell Phone Number:_______________________

Email Address:____________________________________________________

United States/local address: (Required by Dept. of Homeland Security)

Address________________________________________________________________________________
City_______________________________________ State _______ Postal/Zip Code ___________
Telephone: (Home) ______________________________ (Cell)______________________________
Enrollment Plans
I am applying for admission to: (Check one or both)
English Language Program (ESOL) _______ An Academic program in______________________________________
I plan to begin studying in the: Fall 20_____ Spring 20______ Summer ______

IF YOU ARE MARRIED AND IF YOUR SPOUSE AND/OR CHILDREN WILL ACCOMPANY YOU, PLEASE PROVIDE NAMES, DATES AND PLACES OF BIRTH
COMPLETE NAME DATE OF BIRTH COUNTRY OF
RELATIONSHIP COUNTRY OF BIRTH
(IN PASSPORT) (MM/DD/YYYY) CITIZENSHIP
SPOUSE □ MALE □ FEMALE
CHILD □ MALE □ FEMALE
CHILD □ MALE □ FEMALE

Emergency Contacts
Contact in Home Country Last Name_______________________________________ First Name____________________________

Telephone number (with country and city code) _______________________________________

Contact in United States Last Name________________________________________First Name____________________________

Telephone Number(s)__________________________________________________________

I certify that the names, dates and other information that I have provided on this International Student I-20 Application Form are
true, correct and complete, and that all the documents submitted in support of this application are real, bonafide and verifiable.

I understand that it is mandatory that I be enrolled in at least 12 credit hours per semester in my degree plan and maintain a
minimum 2.0 grade point average while studying at San Jacinto College to maintain my F-1 Status.

____________________________________________________________ __________________________________
Signature of Applicant Date

Revised 9/10/15