Personal Information:
Study Abroad Program:
Country:
Last Name:
First Namer:
Middle Name:
BU ID:
E-mail Address:
Current Address:
Permanent Address(if different):
Parent(s) Address(if different):
Emergency Contact:
Name:
Relationship:
Adress:
To which address should your billing statement be sent during
the program?
May Benedictine University release your name and address
to present or potential participants?
Yes
No
Will you be traveling on a U.S. Passport?
Yes
No
If not, from which country?:
What is your passport's expiration date?:
Age:
Date of Birth:
Place of Birth:
Spouse/Children (names, ages, citizenship):
Will they accompany you during the program?
Yes
No
Academic Information:
If non-Benedictine student, specify the name of the college
or university attending:
Do you receive any tuition waivers?
Yes
No
If "yes," explain:
Will you be applying for financial aid?
Yes
No
If "yes," check with the Financial Aid Office
now.
Major, Prospective Major(s):
College of::
Minor, Prospective Minor(s):
College of:
Current Classification (circle one):
Freshman
Sophomore
Junior
Senior
Graduate Other:
Class standing at beginning of on-site phase of study abroad
experience (circle one):
Freshman
Sophomore
Junior
Senior
Graduate Other:
High school from which graduated:
Name of School
City, State
Year Graduated
List in chronological order all schools attended since high
school; include current university or college.
Name, Location & Period Attended of the Institution Degree
Earned
Cumulative GPA (A = 4.0) in all university courses:
Please list the courses you will have taken prior to the
program that fulfill requirements for participation in the
program (e.g. language courses or thematic courses). Please
also list any other courses(include the Title, Credits, Grade,
Semester and Year) you will have taken that would prepare
you for the programt:
Foreign languages studied:
Current level and years of study of program-specific language:
Anticipated level prior to departure:
GPA in foreign language courses (specific to program):
Personal Profile:
In approximately 250 words, please state how this program
suits your academic and personal goals. Attach additional
sheets if necessary.
Participants have strengths and weaknesses relevant to their
participation in the program. Please identify yours.
Have you ever lived, traveled, or studied in another country?
Yes
No
If "yes," please describe and include dates:
For our records, please tell us how you learned about this
program:
Recommenations:
The enclosed recommendation forms should be given to three
professors who know you well; professors should submit the
forms directly to the International Center. Please list references
below.
Name College
of
NOTE: Recommendations will be used only for the purposes
of evaluating your qualifications for admittance to the program
specified on this application; they will not be available
to any other institution, organization, or private party.
Miscellaneous Information:
The following questions are optional. Please circle the appropriate
response.
Gender :
Female
Male
Citizenship:
U.S. Citizen
U.S. Resident Alien
Nonresident Alien
International Student
Predominant Racial/Ethnic Group:
American Indian, Alaskan Native
Asian, Pacific Islander
Black, non-Hispanic (African American)
Hispanic - Chicano/Mexican-American
Hispanic - Puerto Rican, Cuban, or other
White, non-Hispanic (Caucasian)
Agreement:
Release of Information: The collection, retention, dissemination
of your records and personal information is subject to federal
regulations under the Family Education Rights and Privacy
Act of 1974. Therefore, it is necessary for the Study Abroad
Program of Benedictine University to obtain your permission
to release information collected on the application, in your
letters of recommendation, and in your transcripts. We need
your agreement to the following: I hereby release information
contained in my applications for admission and for study abroad,
letters of
recommendation, and transcripts to Benedictine University's
Study Abroad Program for review and approval of my study abroad
application. I grant permission for access to medical, disciplinary,
and counseling files that have bearing on my application.
I hereby release information contained in my application,
letters of recommendation, and transcripts to the overseas
school where I wish to be placed.
Indebtedness: Failure to make full payment of all required
fees or to resolve other debts to the host institution or
Benedictine University (e.g. unreturned equipment, overdue
loans, lost library books, or obligations to the host institution
or to Benedictine) may result in the cancellation of pre-registration
for the following semester, denial of registration until payment
is made, and/or disenrollment at Benedictine University or
the host institution. Release for off-campus study: Benedictine
University assists its students in making off-campus study
arrangements only as a service to its students. It is acting
solely as an agent for its students and, therefore, does not
make any warranties of any kind, expressed or implied, regarding
any off-campus program in which a student may participate.
Benedictine assumes no
responsibility and disclaims any liability or damages or injury
suffered by any student by reason of the negligent or wrongful
acts or failures to act of any person or institution with
whom the University may make arrangements for any off-campus
study program. The term Benedictine University, as used above,
includes the Board of Trustees of Benedictine University,
its successors and its agents, servants, and employees. I
have read the above paragraphs, I understand them completely
and by signing below, I acknowledge my agreement to be bound
by their terms as condition of my participation in any off-campus
programs sanctioned by the University.
I also certify that all statements made on this study abroad
application, in its entirety, are true and accurate.
Benedictine University does not discriminate on the basis
of race, color, national origin, religion, sex, age or handicap
in admissions,employment or the provision of services. Inquiries
regarding this policy should be addressed to the Dean of Administration.
Please print a copy of your completed form for
your records
