Exchange Visitor Application Form
Length of Exchange Visit:
☐ Fall Semester 2015 (August 2015 – December 2015)
☐ Spring Semester 2016 (January 2016 – May 2016)
☐ 2015/2016 Full Academic Year (August 2015 – May 2016)
Partner university where you are currently enrolled? ___________________________________________________________________
Has your home university approved you for an exchange visit to Pacific University?
☐ Yes
☐ No
Surnames (Family Names/Last Names): ______________________________________________________________________________________
(Please write names exactly as they appear on your passport)
First (Given) Names: _____________________________________________________________________________________________________________
Middle Names (if any): __________________________________________________________________________________________________________
☐ Male
☐ Female
Date of Birth: ___________________________________________________________________
MONTH
DATE
YEAR
Permanent Home Country Address: ___________________________________________________________________________________________
Required for issuing immigration documents
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Telephone: ____________________________________________ Cell/Mobile: ______________________________________________________________
Please include country code and any area/city code
Email: ________________________________________________________________________________________________________________________________
Please Type or Write Clearly
Country of Birth: _____________________________________
City of Birth: _______________________________________________
Country/Countries of Citizenship: _____________________________________________________________________________________________
Country/Countries of Passport: _________________________________________________________________________________________________
Are you currently authorized to live permanently in any country other than your citizenship country?
☐ No ☐ Yes: country name? ________________________________________________________________________________________________
What is your US immigration status at this time?
☐ I have no US visa at this time
☐ I’m a US Citizen
☐ I’m a US Permanent Resident
☐ I have an F-1 visa
☐ I have a J-1 visa
☐ Other ___________________________________________________
What is your current academic major (specialization)? __________________________________________________________________
Have you ever been convicted of a felony? ☐ Yes
☐ No
A felony in the USA is an offense for which a prison term can be assigned. If yes, you must attach an explanation.
Full Name of
High School/College/University
previously attended
Address, City and Country of
School/College/University previously
attended
Certificate/Diploma/Degree
Awarded and Major or Academic
Specialization
(if applicable)
Dates of Attendance
Month/Year to Month/Year
Note: Students for whom English is not their native language are required to submit results of an English proficiency test. Required
score is IELTS 6.5 or TOEFL 79 IBT, TOEFL 213 CBT or TOEFL 550 PBT unless otherwise specified by the exchange agreement
between your university and Pacific University
Is English your native language?
If no, English proficiency test type
☐ Yes ☐ No
_____________________ Score
____________________ Date of Test _________________
Application Checklist:
Documents must be submitted to the Exchange Coordinator at your home university.
☐
☐
☐
☐
☐
☐
Completed Application Form
Copy of passport ID page (page with your photograph)
Original of most recent transcript
An original of your most recent transcript from your home university must be submitted directly by your
Registrar’s Office to your on-campus exchange coordinator, who will include it with the application packet
s/he sends to Pacific.
Short Essay: Please write a short (1 – 2 pages double-spaced) essay answering one of the following questions:
1) Discuss your educational goals. How will visiting Pacific help you reach these goals?
2) Discuss an important personal, local, national, or international topic, and discuss why it is important to
you
3) Choose a quotation from a book, movie, song, or famous person, and discuss why it is important to you.
TOEFL/IELTS score report, if English is not your native language
(unless otherwise specified by the exchange agreement between your home university and Pacific University)
Completed Financial Affidavit form with supporting financial documents*
*Kansai Gaidai University students are not required to submit the Financial Affidavit form
“I certify that the information in this application is complete and correct. I understand that if I include
incomplete or false information, Pacific University may reject my application, withdraw an offer of acceptance,
or cancel my enrollment at any time. I give permission for Pacific University to confirm any information on
this application or documents sent in support of this application. I will notify Pacific University of any changes
to this information”
Signature of Applicant
Date (month/day/year)
Pacific University respects your privacy. This information will be used only for admissions purposes. Pacific university does not discriminate on the basis of sex,
disability, race, color, national origin, sexual orientation, age, religion or veteran status in admission, employment, education al programs, or activities as required by
Title IX of the Education Amendments of 1972, section 504 of the Rehabilitation Act of 1973, Title VII of the Civil Rights Act of 1964, the Age Discrimination Act, the
American with Disabilities Act of 1990, and their implementing regulations.
Exchange Visitor Financial Affidavit
All exchange visitors must show they have enough money to afford the costs of their program. Exact program costs are determined
by the exchange agreement between your university and Pacific University.
Some exchange visitors will need to pay Pacific University for tuition, fees, housing and/or meals, while other exchange visitors will
have those costs covered by the exchange agreement.
The Pacific University Office of International Programs will advise you in your admission letter of the minimum funds that you will
need to demonstrate in order to receive your visa.
Please note that, in addition to this form, you must also give us an official bank statement prepared within the last 6 months.
STUDENT SIGNS HERE
“I certify that the information on this form is complete and correct. I understand that if I include incomplete or false information,
Pacific University may reject my application, withdraw an offer of acceptance or cancel my enrollment at any time. I give permission
for Pacific University to confirm this information. I will notify Pacific University of any changes.”
Student’s Signature_____________________________________________________
Date_________________________
Month / Day /Year
You may use more than one source of support, if necessary. Copy this document for use by multiple sponsors.
Sources of Support
Amount of Support
Additional Information
1) Student’s Personal Funds
US$_____________
2) Family Funds
US$_____________
_________________________________
3) Government Scholarship
US$_____________
_________________________________
4) Other (sponsor)
US$_____________
(Relationship to student)
(Source of scholarship)
_________________________________
(Relationship to applicant)
I/we agree to provide the funds shown above to the applicant for the purpose of study at Pacific University.
Please supply bank documents, created in the past 6 months, showing the availability of these funds.
______________________________________________
__________________________________
________________________________
Family Member or Financial Sponsor Printed Name
Family Member or Financial Sponsor Signature
Date (month/day/year)
_________________________________________________________________________________________________________________________________________
Family Member or Financial Sponsor Address Line 1
_________________________________________________________________________________________________________________________________________
Family Member or Financial Sponsor Address Line 2
_________________________________________________________________________________________________________________________________________
Family Member or Financial Sponsor Address Line 3
Please submit this form and required bank documents to your on-campus exchange coordinator, who will include it with the
application packet s/he sends to Pacific.
If you have questions about program costs or other program features, please see our Exchange Visitor information online.
http://tiny.cc/mbwwpx
Exchange Visitor Housing Information
Please note: Students on programs which include an exchange of housing will usually be assigned shared rooms in
the Residence Halls. Students on programs where housing is not covered by the exchange agreement and visitors
pay Pacific directly can request a particular type of room. While Pacific cannot guarantee that students will receive
their requested room type, housing will always be provided for exchange students.
Residence Hall (dormitory)
Pacific University has 4 residence halls on campus. Each one has a full-time professional live-in manager, and several
senior students who act as assistant managers. For security the outside doors are always locked. Usually two
students share a room, although some rooms are designed for 3 or 4 students to share. Residence halls have shared
bathrooms located along each corridor, although a few rooms have en-suite baths. All rooms are furnished and have
internet and wi-fi connections. Residence halls have a laundry room, recreation room, vending machines and a
community kitchen that can be used for preparing snacks. Students living in a residence hall must have a meal plan
for the campus cafeteria (refectory).
On-Campus Apartment
Pacific has 3 University-owned apartment buildings on campus for older students. Each apartment has between 2
and 6 bedrooms, a living room, and 1 or 2 bathrooms. All rooms are furnished. Each building has internet
connectivity and laundry facilities, and most buildings have recreation rooms as well. Many apartments feature
kitchens, and students living in an apartment with a full kitchen can choose from several different meal plans, or can
choose to cook for themselves. The on-campus apartments also have full-time professional managers and staff who
are available 24-hours a day.
Meal Plans
Exchange visitors assigned to standard university housing that does not include a full in-room kitchen must have a
university meal plan. Exchange visitors assigned to apartment-style university housing with a full in-room kitchen
(generally reserved for students 20 or older) may choose to have a meal plan, self-cater by purchasing food at local
stores and cooking, or a combination of both.
The Forest Grove campus has a variety of dining locations. Dining options include The Grove dining room for full
meals, a Starbucks café, and the P.O.D. convenience store with snacks and quick meals. The university meal plans can
be used in all dining locations, and anyone without a meal plan can make cash purchases. The cost of a one-semester
meal plan in 2014/2015 is $2716.
If you have more questions about housing, meals, or other program features, please see our Exchange Visitor information online.
http://tiny.cc/mbwwpx