Office of Global and Multicultural Education
2016-2017 Tuition Waiver Application for International Students
NAME: _______________________
Last (Family) Name
______________________
First Name
___________________
Middle Name
Student ID Number _____________________
Specify the semester and year you are applying for:
 Fall 2016
 Spring 2017
 Summer 2017
Tuition Waivers granted are for a reduction 50% in out of state tuition rate.
Application Deadlines: April 15 (Returning Students and New Students for Summer semester)
June 30th (New Students for Fall semester)
November 15th (New Students for Spring semester)
PLEASE READ ALL INSTRUCTIONS AND INFORMATION CAREFULLY.
•
Submit all required documentation listed below by email to dwallick@bloomu.edu or the
Office of Global and Multicultural Education, Student Services Center, Room 236
no later than the semester deadlines above.
Required Documentation:
• Tuition Waiver Application  (Part I, Part II, Part III)
• Supporting Financial Documents (Letters of support, additional pages for explanation,
etc.) 
• Activities Report Form  (for returning students only)
Direct all questions concerning these forms and/or the tuition waiver application process to Ms.
Nawal Bonomo, Director, nbonomo@bloomu.edu Telephone: 570-389-4199, Fax: 570-389-4830.
1
Office of Global and Multicultural Education
PART I
Biographical Information
1. Visa Type
2. Passport #
3. Male
4. Date of Birth
Female
6. Country of Citizenship
5. Marital Status
(month/day/year)
7. Currency/ Rate of exchange
8. U.S. Address
9. Email Address
11.
10. Telephone Number
Major
12. Expected Graduation Date
(month/year)
13. Has there been any change in your status since you were admitted to Bloomsburg University? (visa,
citizenship, etc.)
No
Yes
(If yes, please explain on back.)
Part II
Contributions to Globalization
PASSHE guidelines for this waiver state the international students must have “demonstrated ability and
efforts to contribute to globalization of the University and community.” Programs and/or activities in which
you have been involved on and off campus and your role in each should be reported on the Activities Report
Form (Separate form – for returning students only).
1.
Recent Programs and/or activities: Organizations, through the community, or informal activities.
2.
In the future, how will you share your culture and international experiences with the campus community or
the community-at-large?
2
Office of Global and Multicultural Education
Part III
Financial Needs Assessment
Marital Status _____________ Are you supporting children?  yes  no If yes, how many? ___
Are your parents supporting other children?  yes  no If yes, how many? _____
Student’s Yearly
Assets - Savings, cash, CD’s, Investments in stock Net worth of real estate
(current value minus debt)
and bonds, etc.
Income
$
$
Father’s Yearly
Income
Father’s occupation
$
$
Mother’s Yearly
Income
Mother’s
occupation
$
If combined income is less than $1000, please explain on back or attach an additional sheet.
Assets - Savings, cash, CD’s, Investments in Net worth of Real Estate (current
Parent’s Combined
Assets
stock and bonds, etc.
value minus debt)
$
$
Anticipated Sponsor Support during school year
Sponsor’s Support
Attach a letter of sponsor
support to this application
$
Government Support
Anticipated Government Support during school year
Attach a letter of government
support to this application
$
Student’s Signature _________________________________________
Date ____________
Father’s Signature __________________________________________
Date ____________
Mother’s Signature _________________________________________
Date ____________
For Official Use Only
 Eligible (half waiver)
 Not eligible
Financial Aid Director Signature ______________________________
Date ____________
International Tuition Waiver Chair _____________________________
Date ____________
3
INTERNATIONAL WAIVER ACTIVITY REPORT FORM
First and Last Name ________________________________________________ BU ID #___________________
(please print)
SEMESTER:
Fall
Spring
Summer
Date
Record your service projects/events and submit this form
Submit to the Office of Global and Multicultural Education,
SSC 236
Service Project/event
Amount
of hours
Agency verification signature & date
4