STUDY ABROAD APPLICANT INFORMATION FORM Kutztown University KU Winter Program in London 2016-2017 Applicant’s Name___________________________________Student ID #_________________________ Gender_______ Date of Birth ___/___/___ Country of Birth _________________ Country of Citizenship______________ University/College currently attending______________________________________________________ Campus Address _____________________________________________________________________ (Number and Street) (City/State/Zip) Campus Phone __________________________ Campus e-mail ___________________________ Date after which you will no longer be at this campus address __________________________________ Permanent address ________________________________________________________________ (Number and Street) (City/State/Zip) Cell Phone _____________________________ Permanent e-mail ________________________ Major (if declared) _______________________ Minor _________________________________ GPA in Major _______ Overall GPA _______ Expected Semester/Year of Graduation ________/___________ Please rank-order your course preference (e.g. 1st choice, 2nd choice etc. Priority will be given to preference) ________PSY 290CD ________ HIS 205 ________ ENG 283 _________ AST 018 (If you are unable or unwilling to take a particular course, please mark it with an “N”.) Psychology/History/English/Physical Science courses you have completed: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ over -------------> Please answer the following questions, in the space provided, as specifically as possible without repetition in your answers. 1) Why do you want to participate in the KU Winter Program in London? 2) What goals/achievements do you hope to obtain from this program? 3) Please write a short personal statement indicating things such as your major program of study at KU, personal interests outside the classroom, hobbies, etc. 4) What sort of activities or experiences have you had that illustrate your adaptability and flexibility to diverse and/or foreign cultures and peoples? 5. Please identify one Kutztown University professor who may be contacted as your reference: Reference Name_______________________ Department__________________ email__________________ _____________________________________ Your signature ____________ Date Please return this form to Dr. Derek Mace, Old Main 378 or his mailbox in Old Main 384 Applications accepted immediately. Final decisions to be made before September 30.