THE CALIFORNIA STATE UNIVERSITY



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|CSU CHANNEL ISLANDS STUDENT EXCHANGE APPLICATION FOR: | |

|Term(s) of study on exchange: | Fall semester | | Spring semester | |

|Planned Period of Study on Exchange: From: | | To: | | |

Month / Year Month / Year

I. APPLICANT INFORMATION

INSTRUCTIONS: Pages 1 and 2 of this application MUST BE TYPED. Keep a copy of your completed application for your records,

A. PERSONAL INFORMATION

|1. Are you a US citizen by birth or after |Yes: | |No: | |If yes, do not proceed. US citizens are not eligible for this exchange. |

|birth through parents or naturalization? | | | | |If no, please proceed with completing this application. |

|2. Applicant’s Legal Name: | |

(as it appears in your passport) Family/Surname (Last) Name Given (First) Name Middle Name

|3. Date of Birth: | |

City State/Province Country

|6. Country of Citizenship: | |7. Country of Permanent Residence: | |

|8. Addresses |Current Address |Permanent Address |

| |Valid from: | | Until: | |(If different than your current address) |

| | Month/Year | |

| |Month/Year | |

|Street and Apartment #: | | |

|City: | | |

|Province/State: | | |

|Country and Postal Code: | | |

|Telephone Number: | | |

Country Code City Code Number Country Code City Code Number

|9. Email Addresses: | | |

Preferred Email Address Alternate Email Address

B. ACADEMIC INFORMATION

|10. Applicant’s Home University: | | |

|11. Field(s) of Study at Home Institution: | |

|12. Principle Field(s) of Study during Exchange: | |

|13. If available, are you interested in applying for on-campus housing? | Yes: | |

Student’s Family (Last) Name, First

II. VERIFICATION OF FINANCIAL SUPPORT

All exchange student applicants are required to complete Section A below and submit this form with their exchange application to show that they have access to $10,000 per term.

To verify that you have funds available to you while on exchange, you must provide official bank documentation, which shows that you and/or your sponsor(s) have the minimum required amount of financial assets available to you while on exchange. Bank statements must be recent. It is recommended that you show funds in excess of the amounts shown since exchange rates can vary.

Due to exchange rate fluctuations and cost of living increases in California, it is advisable to provide more funding that the required amounts listed above.

A. Sources and amounts of financial support available while studying at CSU

| |In National Currency |

|Your own funds: | |

|Funds from sponsoring parents, friends, relatives: | |

|Government scholarship or sponsoring agency: | |

|Total amount: | |

Month / Day / Year

If you will use a sponsor to satisfy this financial obligation, then your sponsor must either sign below under Certification of Financial Sponsor or provide a letter declaring their relationship to the student and their intent to provide financial support throughout the student’s period of study at CSU Channel Islands. If more than one sponsor will provide financial support, each sponsor must provide a separate letter declaring intent to sponsor. Each sponsor must provide a signed bank statement or a letter from their bank showing the availability of the necessary funds.

B. Certification of Financial Sponsor (or provide letter from your sponsor)

"I guarantee that $______________ (in U.S dollars) will be available to the above-named student for his/her study at the CSU."

|Name of sponsor: | |

|Address of sponsor: | |

|Relationship to student: | |

|Sponsor's signature: | | Date: | |

Month / Day / Year

C. Verification by Bank Official (or provide a letter from your bank or provide bank statements)

"I certify that ________________________________ has deposited in this bank the equivalent of (U.S. dollars) $ ."

Given (first) name Surname/family name

|Name and position of bank official: | |

|Name and address of bank: | |

|Bank stamp or seal: | |

|Signature of bank of official: | | Date: | |

Month / Day / Year

III. ENGLISH LANGUAGE PROFICIENCY

Applicants who have not attended an education institution at the secondary level or beyond where English is the principal language of instruction for at least three years are required to take an English proficiency exam. Acceptable exams are:

• 6.0 IELTS

• 61: ETS TOEFL (internet-based score)

• DAAD: B or better

• Eiken Pre-1

| |Student Name: | PAGE 3 |

|CSUCI STUDENT EXCHANGE APPLICATION FOR: | | |

IV. HEALTH INSURANCE

International students are required to purchase and maintain health insurance through JCB Insurance. The website is: . Students must purchase this specific insurance, regardless of what insurance students may already have. Exchange students will also receive information about health insurance requirements once accepted. Proof of health insurance must be submitted at least one month prior to program start date. Failure to purchase the JCB health insurance will result in the student’s admittance status being terminated.

V. STATEMENT OF UNDERSTANDING

I understand and agree that if I am admitted to CSU Channel Islands (CI) as an international exchange student that:

• I will take part in exchange program-related activities at CI including attending the mandatory orientation session for international exchange students before the semester begins. I understand that I am considered a representative of my home country and university and that my active participation at CI is essential to the sustainability of the exchange program.

• I must be flexible in the selection and scheduling of courses (subjects) that I wish to take. I understand that enrollment of specific courses are not guaranteed. I must also not expect to take subjects in areas of study which are impacted.

• I am required to maintain good academic standing and to register in and maintain full-time enrollment each term.

• I have the necessary funds to support me for the length of my exchange as reflected in the amounts disclosed in Page 2 of the Application: Verification of Financial Support. While the CI tuition fees are waived for exchange students, I am required to pay other costs that I incur at my host campus by the deadline date(s) given to me pertaining but not limited to the following: housing, transportation, student ID card, phone usage, utilities, textbooks, health services, student activities.

• I must purchase and maintain health insurance (as indicated in Section IV) for myself.

• I allow CSUCI to communicate with the international office at my home university regarding my application and exchange semester at CSUCI.

• I understand that I may need to pay the fees for any classroom related charges for certain classes (e.g. lab fees).

• I must obey the regulations and policies of my host university as well as the laws of the State of California and the USA.

|Student Signature: | | Date:| |

Month / Day / Year

VI. SUBMISSION OF APPLICATION

Submit the signed application plus the following forms and documents to the Exchange Coordinator at your home institution.

❑ Verification of Financial Support and supporting documents.

❑ Copy of the page of your passport showing your photo, full legal name and place of birth.

❑ TOEFL, IELTS, DAAD or EIKIN test results (if applicable).

❑ Official transcripts of ALL tertiary/university study listed on page 1 (Question 15)

Your application cannot be considered without the above items. If you are admitted to CI, International Programs will issue a letter of admission and a DS-2019 (Certificate of Eligibility for Exchange Visitor Status) which will be forwarded to your home university Exchange Coordinator. The DS-2019 from CI enables you to apply for the J-1 visa. Do not plan on leaving your country of residence until you have been issued the visa; it will allow you to enter the United States 30 days before the program start date.

VII. HOME INSTITUTION ENDORSEMENT (to be completed by your Exchange Coordinator)

I verify that the student will be enrolled in a degree program at his/her home institution during the proposed period of exchange. I have verified that the student is submitting a completed application which includes the documents listed in Section VI. After reviewing the student’s application, I recommend the student’s participation in this exchange.

|Printed Name: | | Title of Position: | |

|Signature: | | | |

| | |Date: | |

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