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.