Kutztown University
Application Packet
Outgoing Students
National Student Exchange
NSE Office
Boxwood House
Kutztown University
Kutztown, PA 19530
KU NSE Application and Placement Procedures
The following application procedure will direct you through the process that is used at Kutztown University to ensure that NSE is
both appropriate and beneficial to you.
1.
Read NSE Student Guide and pay particular attention to the beginning sections which describe the overall process of exchange
and how to get the most out of the Guide. As you read, you should think in terms of your personal and academic goals and
objectives. Additional information about NSE and connections to the profiles of member campuses can be found on the NSE
home page, www.NSE.org.
2.
It is suggested that you write your exchange goals and objectives on paper. Include both personal and academic goals.
3.
Discuss your plans with your academic advisor, parents, friends and the staff in the NSE Office.
4.
Read the whole application prior to providing the information requested.
5.
Carefully complete the application.
NOTES
A. Please fill out the information being requested thoroughly and completely. We are especially interested in how we can get
in touch with you by both phone and e-mail.
B. When you get to the “Scholastic and Other Information” make sure you indicate your GPA. The minimum requirement for
participation in NSE is a GPA of 2.50 earned at Kutztown University. Some campuses have higher GPA requirements. If
you choose to go on exchange for more than one term, you should earn at least a 2.50 GPA at your host campus in your
first term in order to remain for subsequent terms. Please note that you are also required to have a minimum of 24 credits
earned prior to going on exchange. If you do not meet either requirement, your exchange will be canceled.
C. Under “Exchange Requests” you are asked about the period of exchange you desire. If there is the possibility that you will
stay for the full academic year, you should indicate that. It is often impossible to extend and exchange into another
semester if it was not requested at the time of placement. There is no problem in returning to Kutztown University for a
second semester here rather than remaining at the host campus if that is necessary.
D. You have been given five lines on which to list possible exchange sites in priority order. Feel free to attach a sheet of
additional choices, but DO NOT list any campus that you would not attend if placed there. We will try to place you at your
first choice campus; we cannot guarantee that and may have to place you at a second or third choice.
E. There are three reference forms that you need to complete. One is designated for your academic advisor, another for
someone else from the Kutztown University faculty or staff, and one for whomever you choose. We prefer parents or other
relatives when appropriate, but it could be from another faculty member, an employer, a clergyman or whomever you
choose. Make sure that you list the names and telephone numbers of people from whom you request references. If
recommendations do not arrive in a reasonable length of time after we receive your application, we will contact the person
to whom you gave the form.
F.
If you are listing Puerto Rico or Quebec, you will need to have your Spanish or French skills evaluated. Please complete
the Language Proficiency Report.
G. We would like your parents to be involved with your exchange and have suggested that one of the recommendations come
from them if you feel it is appropriate. (A reference letter from your parents or other relatives that highlights your personal
development is helpful.)
H. When you complete the “Study Statement”, be sure to be specific and thorough. Indicate the kind of courses you plan to
take. It is your chance to tell us exactly what you want to accomplish on exchange both academically and personally.
Notice that it requires the signature of your advisor or department chairperson.
I.
As part of your application we have included a Budget/Resources Worksheet. You may want to make copies of that and
work it through for the campuses you are considering. It may help you with prioritizing your choices, not to mention
clarifying the affordability of participation in the first place. We will require that you complete the form for your first
choice campus and submit it with the rest of your application. Campus budget estimates to use with this form for all NSE
members can be found in the Student Information section of www.NSE.org.
J.
We require a transcript of your academic work from every campus you have attended. We will obtain the record of your
work here at Kutztown University. It is your responsibility to secure and submit all transcripts from other schools you have
attended.
K. As part of your application, a non-refundable $200 application fee is required in the form of a money order made
out to “Kutztown University” or in cash. Personal checks will not be accepted. A portion of that fee goes directly to
the NSE Central Office for support of the NSE program. The other portion remains in our office to help maintain
the campus program.
L. When your application is complete, you must schedule an interview with the NSE coordinator and/or another faculty or
staff member associated with the program. A student coordinator in the NSE office will do the scheduling. This will
provide a chance for us to review your application with you and for you to ask any questions that may have emerged since
you began the application process.
6.
The processing of your application and decision on your participation in NSE are the responsibility of Kutztown University.
Once it is determined that you are eligible to participate, the potential exchange campuses consider you based only on space
availability. Most placement decisions are made at a national conference held during the first week of March and include
placements for the spring semester as well as the fall and full academic year.
7.
Immediately following the placement conference, you will be notified of your placement and asked to sign a “Placement
Acceptance Form” that will be mailed later to your host campus.
8.
You will then receive information regarding housing, meal plans, tuition, registration and any other information you will need
to know. It is your responsibility to meet all deadlines for the host campus including bills and registration.
9.
You will complete an advising agreement with the help of your academic advisor. It will be your guarantee of the course
compatibility between the courses you take at your host campus and your Kutztown University academic program.
10.
Soon you will be attending your new campus, making friends and seeing new places. When you arrive, we ask that you
send a postcard to us with your address and telephone number. It is important that we know how to contact you in case
of an emergency.
11.
At the end of your exchange you must request a transcript to be sent from the host transcript office directly to the NSE Office,
Boxwood House, PO Box 730, Kutztown, PA 19530. Because NSE is an officially approved program of Kutztown University,
all courses with their respective credit hours will be recorded on the Kutztown University transcript as transfer courses. Please
take note that only the credit hours would be recorded on your Kutztown University transcript. The grades you earned at your
host institution would neither transfer nor count towards your cumulative grade point average at Kutztown University.
Application for Exchange
Deadline for Priority Placement: February 1
Application Deadline: Fall: April 1
Spring: November 1
Date Application Submitted: __________
Nonrefundable Application Fee Received: _______
The application is not considered complete until the fee has been paid.
Prior to completing this application, read:
 NSE eligibility requirements, policies, and procedures (pages 11-17 of the NSE Directory)
 Campus NSE policies and procedures
RETURN THIS FORM TO:
Nicole Becker
Office of International Admissions
Boxwood House
Kutztown University
484-646-4256
studyaway@kutztown.edu
T
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CONTACT INFORMATION
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Name: First ________________________________ Middle _________________ Last__________________________
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Current Address:
c
Street/Residence Hall and Room ________________________________________________________________
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City, State/Province, and Zip/Postal Code_________________________________________________________
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Street______________________________________________________________________________________
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City, State/Province, and Zip/Postal Code_________________________________________________________
d
Permanent Address:
Current Phone ______/_______________ extension ___________
Permanent Phone ______/______________
c
Cell Phone______/_________________________
E-mail ________________________________
Alternate E-mail
Campus I.D. Number ___________________________
DEMOGRAPHIC INFORMATION
Date of Birth (MM/DD/YYYY): ________________________
o
m
p
___________________________________
l
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t
e
Gender:  Female  Male
Are you currently living in on-campus housing?  Yes  No
Are you a resident of the state/province in which your home campus is located?  Yes No
Country of Citizenship:  United States  Canada  Other ________________________________________
 Non-resident alien — If non-resident alien, visa type_______________
u
n
t
i
l
t
h
e
 Lawful permanent resident
f
e
Primary reason(s) for exchange - check all applicable
 access different courses/faculty
 language study
 participate in host campus international programe
 evaluate graduate schools
 personal growth
 other: _______________________________ h
a
 live in a different area
 enter host campus honors program
s
 exchange as a resident assistant
 look for future employment
b
e
SCHOLASTIC AND OTHER INFORMATION
Current Class Level:  Fr  So  Jr  Sr
Class Level While on Exchange:  Fr  So  Jr  Sr
Cumulative grade point average: ____________
Major: ________________________________ Minor: _______________________________
Will you need courses in your major while on exchange?  Yes  No
Are you requesting financial aid (Plan A) from the host campus?  Yes  No
Are you currently receiving financial aid?  Yes  No
Where do you plan to reside at the exchange school?  Residence hall  Sorority/Fraternity  Off-campus
Are you currently enrolled in the honors program?  Yes  No
Marital Status:  Single  Married
Will you be accompanied on exchange by: spouse  Yes  No
children  Yes  No
Do you wish to go on exchange with another student(s):  Yes  No
If yes, name of the student(s) ________________________________________________________________
Name of campus at which the student is enrolled: ________________________________________________
EXCHANGE REQUESTS
Period of requested exchange:  Fall Semester 20____
 Spring Semester 20___
 Fall Quarter 20___  Winter Quarter 20____
 Spring Quarter 20_____
 Summer 20____
List in priority order the institutions you wish to attend and the tuition payment plan(s) you could use.
(Use an additional sheet if more than five institutions are requested.)
Name of Institution
Tuition Payment Plan
Plan A=You pay in-state/resident tuition/fees to your host campus.
Plan B=You pay your normal tuition/fees to your home campus.
1. ____________________________________________
___A only ___B only ___A or B (prefer ___)
2. ____________________________________________
___A only ___B only ___A or B (prefer ___)
3. ____________________________________________
___A only ___B only ___A or B (prefer ___)
4. ____________________________________________
___A only ___B only ___A or B (prefer ___)
5. ____________________________________________
___A only ___B only ___A or B (prefer ___)
EDUCATIONAL BACKGROUND
Number of credits completed to date: _________ Number of credits enrolled in current term: _____________
Expected graduation date:__________________
Do you have any incomplete grades, missing grades, or other deficiencies (e.g. failure to complete required
proficiency tests)?
 Yes
 No
If yes, please explain:________________________________________________________________________
Activities, positions, honors while in college:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SPECIAL NEEDS OR CIRCUMSTANCES
If you have a physical condition for which accessible, on-campus housing or classroom accommodation might be
needed; a documented disability which may require academic accommodation (e.g., notetakers, taped texts); a medical
condition which might require immediate attention during exchange; or a condition which might affect emotional or
mental well-being during exchange, you are encouraged to identify your needs by attaching a separate page indicating
the nature and extent of your circumstances and arrangements which are currently being made for you on this campus.
Also indicate whether or not we may contact your requested host campuses at this time.
NSE does not discriminate on the basis of special needs. Rather, your disclosure at this stage of the application process is
invited in order to assist you in identifying a placement site which can provide reasonable accommodation of your needs.
Following placement, it is your responsibility to consult the host campus coordinator and ADA officer to determine the
deadlines by which you must submit written, current, and professionally documented information as required by your
host campus.
OTHER CONSIDERATIONS
Have you ever been convicted of a felony?  Yes  No
Are you on probation, parole, or have any legal judgments pending against you either inside or outside campus?
 Yes  No If yes, please explain:
Are you currently under any campus disciplinary action for violation of codes of academic or student conduct?
 Yes
 No If yes, please explain:
Do you have any outstanding indebtedness to the campus?  Yes  No
LANGUAGE PROFICIENCY
What is your native language?  English  French  Spanish  Other:___________________________________
If you plan to exchange to a campus in Puerto Rico, you must be certified for proficiency in Spanish. If you plan to
exchange to a French-speaking university in Canada, you must be certified for proficiency in French. If English is not
your first language, for all other NSE locations you must demonstrate proficiency in English. Language proficiency must
be determined prior to placement.
RECOMMENDATIONS/REFERENCES
List the individuals who are writing references for you. Submit reference forms to your advisor, at least one faculty/staff
member, and one other person who will recommend you for exchange.
advisor
department/office
phone
e-mail
faculty/staff
department/office
phone
e-mail
name
relationship to applicant
phone
e-mail
EMERGENCY CONTACT
Name _________________________________________________ Relationship________________________________
Street ____________________________________________________________________________________________
City, State/Province, and Zip/Postal Code _______________________________________________________________
Phone ______/________________
E-mail ______________________________________________
RELEASE OF INFORMATION
The collection, retention, and dissemination of your records and information about you are subject to federal regulation
under the Family Education Rights and Privacy Act of 1974. You are responsible for specifying the persons or agents
who have access to your records. Therefore, it is necessary that we obtain your permission to request and release
information pertinent to your exchange. Please read the following statements and sign below:
 I understand that it will be necessary for my campus to obtain certain information about my academic and nonacademic record in order to: 1) ascertain my eligibility and suitability for an exchange through NSE, and 2) facilitate
my exchange after it is arranged. I hereby grant permission to the NSE coordinator and/or designee to obtain
information that is appropriate to my application and participation in the exchange including, but not limited to, letters
of recommendation, permanent academic records and transcripts, conduct, fiscal records, medical records, all for the
purposes of exchange placement and participation, continuation, or termination.
 I give permission to the NSE coordinator and/or designee to contact appropriate personnel in order to verify that I am
under no disciplinary action for violation of codes of academic and student conduct and/or that I have no judicial
cases pending which would invalidate my eligibility for exchange.
 I hereby release information contained in my application, letters of recommendation, transcripts, and other
information required as part of the NSE application process to my home NSE Coordinator, designee, and those
individuals/committees responsible for reviewing and approving my application for exchange participation.
 I hereby give permission for the information contained in my application to be submitted on NSE’s restricted, Webbased placement site for the use of the home and host campuses and the NSE Central Office in placement and recordkeeping processes.
 I hereby release information contained in my application, letters of recommendation, transcripts, and other
information required as part of the NSE application process to the National Student Exchange Central Office and to
the NSE host institution at which I am placed.
Signature _________________________________________________ Date ____________________________
SUPPORTING MATERIALS OR OTHER REQUIREMENTS
 unofficial transcript
 recommendations/references
 program of study statement
 statement of personal goals and reasons for exchange participation
 language proficiency report (if applicable)
 interview
SIGNATURE
I have read and fully understand:
 information on eligibility, policy, and procedures presented in the NSE Directory (pages 11-17).
 campus policies and procedures governing my exchange participation.
I further understand that:
 participating in the National Student Exchange is a privilege and not a right.
 submitting an application is not a guarantee of application acceptance or placement.
 failure to maintain (prior to and during my exchange) all of the eligibility requirements of the program and those of
 my home and host campuses will result in the cancellation of my exchange.
 failure to pay all financial obligations to my home and host campuses will result in the cancellation of my exchange.
 I also understand that until financial obligations are met, my home and host campuses will not release transcripts;
and I will not be permitted to re-enroll at, or graduate from, my home campus.
If accepted for participation in the National Student Exchange, I agree to adhere to all the rules and regulations of both
my home and host institutions. Failure to do so will result in the cancellation of my exchange.
I affirm that all information is complete, accurate, and true to the best of my knowledge. I acknowledge that I am signing
freely, voluntarily, and under no compulsion.
Signature _______________________________________________
Date _______________________
Budget/Resource Worksheet
Consider the length of your exchange (part of the academic year or all of the academic year), the number of times you are likely to
travel to and from your home to your host campus, and the cultural and travel/sight-seeing opportunities you would like to take
advantage of while on exchange. Also note:
 Tuition and fees frequently increase from 5-15 percent per year.
 Room and meals frequently increase in excess of 5 percent each year.
 Financial aid while on exchange may vary from that which you currently receive.
Estimated Costs:
Tuition/Fees*
Plan A: Host Tuition/Fees
OR
Plan B: HomeTuition Fees
Host Room and Meals*
Books/Supplies*
Insurance*
Transportation on the
Host Campus*
Personal Expenses*
Other
Travel to/from Host
Miscellaneous
Per Term
Academic Year
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
============ =====
============ ====+
$__________
$_________
* Figures are available from Campus Budgets at
www.nse.org, Students, Resources.
 Calculate Plan B tuition based on the calendar
of your home campus.
 Calculate all other fees, including Plan A
tuition, on the calendar of your host campus.
 For an Academic Year exchange, all estimated
costs (except travel and miscellaneous) at
semester schools are paid 2 times a year. For
quarter schools, payments are made 3 times
a year.
Total Estimated Costs
In addition to costs estimated above, other additional expenses may include fees that are a condition of your enrollment (e.g., general service,
laboratory, art and photography supplies, field experience, student teaching, internship, technology fees, computer fees, etc.) and other fees (e.g.,
application, orientation, field trips, NSE program fees, health services, parking, special events, student activities, athletics, etc.). See NSE Campus
Profiles and campus on-line fee schedules for additional information.
Resources:
Per Term
Personal Savings
Family Support
Federal Grants/Loans
Pell
Work Study
Perkins
SEOG
Direct Loan
Parent Plus Loan
State Financial Aid
Scholarships
Other: ____________
____________
Work during exchange
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
Work Study
Not applicable
on Plan B.
U.S. Federal Financial Aid
 For Plan A: applied for, and disbursed from, the
host campus unless otherwise directed by your
home NSE Coordinator.
 For Plan B: applied for, and disbursed from, the
home campus.
 If exchanging to Canada, aid is applied for, and
disbursed from, the home campus.
Other Aid (i.e., state aid, scholarships, tuition waivers)
Not all aid is applicable to exchange programs and
some may be dependent upon Plan A or Plan B.
Check with your financial aid officer and/or
scholarship source.
========= =====
$__________
Total Estimated Resources per Term
Reference - Academic Advisor
Applicant: please complete this section.
Applicant's Name
In compliance with the Family Education Rights and Privacy Act of 1974, the candidate may have access to this
evaluation unless access is waived by completing the following statement:
I, ______________________________________, waive my right to access this evaluation.
Signature _____________________________________
Date _________________
To the Academic Advisor:
The National Student Exchange (NSE) provides students with the opportunity to attend another member
university within the United States, Canada, Guam, Puerto Rico and the U.S. Virgin Islands for a single term or
an academic year. Students participate in NSE to take advantage of the unique geographic, cultural, and
academic characteristics of institutions and/or regions.
In making decisions on the appropriateness of a student's participation in the exchange, we need to know
about their motivation, adaptability, academic skills, and those personal qualities that will give students the
ability to benefit fully from the exchange experience. While we will appreciate any observations that will
assist us in evaluating the present applicant, of special interest are qualities such as competence,
independence, assertiveness, resourcefulness, quality of performance, confidence, social skills, openmindedness, and integrity.
Please indicate the basis and extent of your acquaintance with the applicant. Placing your remarks in a
comparative perspective will further assist the NSE office in reaching a decision about the applicant.
In summation, please state frankly your opinion of this applicant's chances for academic and non-academic
success in an exchange program, weighing both strong and weak points.
Occasionally, an academic advisor has not had enough contact with a student to do an adequate personal
evaluation. However, in that situation we would like a statement regarding your willingness to work with the
student to determine where courses taken at the host campus will fit into the student's home academic
program. We would also like to know the appropriateness of exchange at this time in the student's program of
study. We are particularly concerned that the student’s academic progress will not be hindered by
participating in NSE. Those statements can be entered in section 4 on the reverse side of this form.
1. How well do you know the applicant? (Check the most appropriate response.)
 Extensive contact in a variety of settings
 Well acquainted in classroom or campus environment
 Limited contact in classroom or campus environment
 Other ______________________________________________________________________
2. In comparison with other students whom you have known at comparable stages of their education,
please rate the applicant in these areas. (Circle the most appropriate response.)
Academic Ability
Maturity
Cooperation and Adaptability
Initiative and Motivation
Social Skills
Open-mindedness
Integrity
Independence
Resourcefulness
Self-Confidence
Excellent
Very Good
Average
Below
Average
Unable to
Judge
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
X
X
X
X
X
X
X
X
X
X
3. Exchange to another campus would be appropriate for the applicant: ___ Yes ___ No
4. Remarks
Based on your knowledge of the applicant, please comment on his/her chances for success and what
would be gained from an exchange experience.
Name (print) ___________________________________
Title
Phone ________________________
e-mail _____________________________________
Signature
Date
__________________________________
Return this form to:
Nicole Becker
Office of International Admissions
Boxwood House
Kutztown, PA 19530
P: 484-646-4256
F: 610-683-1356
studyaway@kutztown.edu
_____________________________________
_____________________
Reference – Faculty/Staff
Applicant: please complete this section.
Applicant's Name
In compliance with the Family Education Rights and Privacy Act of 1974, the candidate may have access to this
evaluation unless access is waived by completing the following statement:
I, ______________________________________, waive my right to access this evaluation.
Signature _____________________________________
Date _________________
To the Faculty or Staff Member:
The National Student Exchange (NSE) provides students with the opportunity to attend another member
university within the United States, Canada, Guam, Puerto Rico and the U.S. Virgin Islands for a single term or
an academic year. Students participate in NSE to take advantage of the unique geographic, cultural, and
academic characteristics of institutions and/or regions.
In making decisions on the appropriateness of a student's participation in the exchange, we need to know
about their motivation, adaptability, academic skills, and those personal qualities that will give students the
ability to benefit fully from the exchange experience. While we will appreciate any observations that will
assist us in evaluating the present applicant, of special interest are qualities such as competence,
independence, assertiveness, resourcefulness, quality of performance, confidence, social skills, openmindedness, and integrity.
Please indicate the basis and extent of your acquaintance with the applicant. Placing your remarks in a
comparative perspective will further assist the NSE office in reaching a decision about the applicant.
In summation, please state frankly your opinion of this applicant's chances for academic and non-academic
success in an exchange program, weighing both strong and weak points.
1. How well do you know the applicant? (Check the most appropriate response.)
 Extensive contact in a variety of settings
 Well acquainted in classroom or campus environment
 Limited contact in classroom or campus environment
 Other ______________________________________________________________________
2. In comparison with other students whom you have known at comparable stages of their education,
please rate the applicant in these areas. (Circle the most appropriate response.)
Excellent
Academic Ability
Maturity
Cooperation and Adaptability
Initiative and Motivation
Social Skills
Open-mindedness
Integrity
Independence
Resourcefulness
Self-Confidence
Very Good
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
Average
2
2
2
2
2
2
2
2
2
2
Below
Average
1
1
1
1
1
1
1
1
1
1
Unable to
Judge
X
X
X
X
X
X
X
X
X
X
3. Exchange to another campus would be appropriate for the applicant: ___ Yes ___ No
4. Remarks
Based on your knowledge of the applicant, please comment on his/her chances for success and what
would be gained from an exchange experience.
Name (print) ___________________________________
Title
Phone ________________________
e-mail _____________________________________
Signature
Date
__________________________________
Return this form to:
Nicole Becker
Office of International Admissions
Boxwood House
Kutztown, PA 19530
P: 484-646-4256
F: 610-683-1356
studyaway@kutztown.edu
_____________________________________
_____________________
Reference – Other
Applicant: please complete this section.
Applicant’s Name ______________________________________
In compliance with the Family Education Rights and Privacy Act of 1974, the candidate may have access to this
evaluation unless access is waived by completing the following statement:
I, ______________________________________, waive my right to access this evaluation.
Signature _____________________________________
Date _________________
To the Evaluator:
The National Student Exchange (NSE) provides students with the opportunity to attend another member university
within the United States, Canada, Guam, Puerto Rico and the U.S. Virgin Islands for a single term or an academic year.
Students participate in NSE to take advantage of the unique geographic, cultural, and academic characteristics of
institutions and/or regions.
In making decisions on the appropriateness of a student's participation in the exchange, we need to know about their
motivation, adaptability, academic skills, and those personal qualities that will give students the ability to benefit fully
from the exchange experience. While we will appreciate any observations that will assist us in evaluating the present
applicant, of special interest are qualities such as competence, independence, assertiveness, resourcefulness, quality of
performance, confidence, social skills, open-mindedness, and integrity.
Please indicate the basis and extent of your acquaintance with the applicant. Placing your remarks in a comparative
perspective will further assist the NSE office in reaching a decision about the applicant.
In summation, please state frankly your opinion of this applicant's chances for academic and non-academic success in an
exchange program, weighing both strong and weak points.
1. How well do you know the applicant? (Check the most appropriate response.)
 Extensive contact in a variety of settings
 Well acquainted in classroom or campus environment
 Limited contact in classroom or campus environment
 Other ______________________________________________________________________
2. In comparison with other students whom you have known at comparable stages of their education,
please rate the applicant in these areas. (Circle the most appropriate response.)
Excellent
Academic Ability
Maturity
Cooperation and Adaptability
Initiative and Motivation
Social Skills
Open-mindedness
Integrity
Independence
Resourcefulness
Self-Confidence
Very Good
4
4
4
4
4
4
4
4
4
4
3
3
3
3
3
3
3
3
3
3
Average
2
2
2
2
2
2
2
2
2
2
Below
Average
1
1
1
1
1
1
1
1
1
1
Unable to
Judge
X
X
X
X
X
X
X
X
X
X
3. Exchange to another campus would be appropriate for the applicant: ___ Yes ___ No
4. Remarks
Based on your knowledge of the applicant, please comment on his/her chances for success and what would be
gained from an exchange experience.
Name (print) ___________________________________
Your relationship to the applicant
_______________________________________________________________
Phone ________________________
e-mail _____________________________________
Signature
Date
__________________________________
Return this form to:
Nicole Becker
Office of International Admissions
Boxwood House
Kutztown, PA 19530
P: 484-646-4256
F: 610-683-1356
studyaway@kutztown.edu
_____________________
Language Proficiency Report
Required for Exchanges to Québec and Puerto Rico &
students for whom English is not their first language.
 If you plan to exchange to a campus in Puerto Rico, you must demonstrate Spanish proficiency since your instruction will
be in Spanish.
 If you plan to exchange to a Francophone university in Canada, you must demonstrate French proficiency since your
instruction will in French.
 For all other NSE member universities, students for whom English is not their first language must demonstrate English
proficiency. Students whose first language is not English, may also be asked to submit TOEFL, IELTS or MELAB scores to
their host institutions following placement.
Return This Form To:
Nicole Becker
Boxwood House
studyaway@kutztown.edu
484-646-4256
Applicant's Name __________________________________________________________________________________
In compliance with the Family Education Rights and Privacy Act of 1974, the candidate may have access to this
evaluation unless access is waived by completing the following statement:
I, ______________________________________, waive my right to access this evaluation. __________________
Signature
Date
What is your native language? ___ English
___French ___ Spanish ___ Other: _______________________
NSE Campus(es) for which you are applying:
Language of Instruction
1.___________________________________________________________
________________________________
2. ___________________________________________________________
________________________________
3. ___________________________________________________________
________________________________
4. ___________________________________________________________
________________________________
5. ___________________________________________________________
________________________________
What courses have you completed, including those in progress, in or related to the language of instruction?
What other experiences have you had in this language? (e.g., lived in the area, spoken at home, read
journals/newspapers)
To Be Completed By The Evaluator
I am evaluating the applicant's ability to receive effective classroom instruction in:
___ English ___French ___ Spanish
Language Assessment
1. The following elements are helpful indicators of the applicant's ability to handle classroom instruction in another
language. Please check which of these elements were used in your evaluation.
Listening Ability
Reading Ability
___ None
___ Limited to slow, uncomplicated sentences
___ Understands simple conversation
___ Understands conversation on simple
academic topics
___ Understands sophisticated discussion
of academic topics
___ None
___ Limited to simple vocabulary and sentence
structure
___ Understands everyday topics and non-technical
subjects
___ Understands materials which contain idioms and
specialized terminology
___ Understands sophisticated materials, including
those in proposed field of study
Speaking Ability
___ None
___ Able to complete structurally simple,
short phrases
___ Uses basic grammatical structure, speaking
with limited vocabulary
___ Uses structural patterns, but not with
consistent accuracy; adequate to
participate in conversational topics
___ Has control over structural patterns; can handle
a wide variety of conversational situations
Writing Ability
___ None
___ Writes simple sentences on conventional topics
with some errors in spelling and structure
___ Writes on academic topics with few errors in
structure and spelling
___ Writes with idiomatic ease of expression and
feeling for the style of the language
2.
How was this evaluation determined?
___ Based on knowledge of the applicant's course work in language at this campus.
___ Written examination.
Date administered
__________________________
___ Oral examination.
Date administered
__________________________
Linguistic Ability
1.What is your opinion of the applicant's ability to pursue university-level course work in this language?
___ Will require considerable training before necessary competence can be attained.
___ Will require additional training before beginning the exchange.
___ Should be able to manage adequately after a short period of adjustment.
___ Should have no difficulty.
2.
Please add any additional comments relating to the applicant's linguistic ability.
Name (print) ___________________________________
Phone ________________________________________
Signature _____________________________________
Title _________________________________________
Email _________________________________________
Date _________________________________________