Application for Exchange
ApplicationDeadline:__February13,2015______________
DateApplicationSubmitted:_______________
NonrefundableApplicationFeeReceived:_______________
Theapplicationisnotcomplete–andnoplacementrequestwillbesubmitted–untilthefee
hasbeenpaid.Shouldyounotbeplaced,beplacedanddeclineyourplacement,acceptyour
placementandlaterwithdraworbecomeineligible,norefundwillbegiven.
.
Priortocompletingthisapplication,read:
• Pages11-24oftheNSEStudentGuide:ExchangePoliciesandProceduresorthesectiononPolicies
andProceduresatnse.org,Students
• CampuspoliciesandproceduresforNSE
TobecompletedbytheNSECoordinator.
_____________________CIPCode(ClassificationofInstructionalPrograms)
Return This Form To:
EmilyFerguson-Steger
NSECoordinatingDirector
101LommassonCenter
Missoula,MT59812
406-243-6268
CredentialLevel:
___02AssociateDegree___03Bachelor’sDegree
___04PostBacc.Certificate)___05Master’sDegree
_____________________ProgramLength
Contact Information
Name:First________________________________Middle_________________Last__________________________
CurrentAddress:
Street/ResidenceHallandRoom________________________________________________________________
City,State/Province,andZip/PostalCode_________________________________________________________
PermanentAddress:
Street______________________________________________________________________________________
City,State/Province,andZip/PostalCode_________________________________________________________
CellPhone______/_______________
HomePhone______/______________
EmergencyPhone______/______________________
CampusE-mail________________________________
Preferred/PersonalE-mail___________________________________
CampusI.D.Number___________________________
NSEApplication–page1of5
Demographic Information
DateofBirth(MM/DD/YYYY):________________________ Gender:qFemaleqMale
Areyoucurrentlylivinginon-campushousing?qYesqNo
Areyouaresidentofthestate/provinceinwhichyourhomecampusislocated?qYesqNo
CountryofCitizenship:qUnitedStatesqCanadaqOther________________________________________
qNon-residentalien—Ifnon-residentalien,visatype_______________qLawfulpermanentresident
Demographic Information,continued
Primaryreason(s)forexchange-checkallapplicableEthnicity(optional)
qaccessdifferentcourses/faculty qevaluategraduateschools
qliveinadifferentarea
qpersonalgrowth
qparticipateinhostcampusinternationalprogram
qenterhostcampushonorsprogram
qexchangeasaresidentassistant
qlanguagestudy
qlookforfutureemployment
qother:_____________________________________
qHispanicorLatino,ofanyrace
qAmericanIndianorAlaskaNative,notHispanicorLatino
qAsian,notHispanicorLatino
qBlack,notHispanicorLatino
qNativeHawaiianorOtherPacificIslander,notHispanicorLatino
qWhite,notHispanicorLatino
qTwoormoreraces,notHispanicorLatino
qNotreported(raceorethnicityunknown)
Scholastic and Other Information
CurrentClassLevel:qFrqSoqJrqSr
ClassLevelWhileonExchange:qSoqJrqSr
Cumulativegradepointaverageatthiscampus:____________(4.0scale)
Major:________________________________Minor:_______________________________
Willyouneedcoursesinyourmajorwhileonexchange?qYesqNo
Areyoucurrentlyreceivingfinancialaid?qYesqNo
Areyourequestingfinancialaid(PlanA)fromthehostcampus?qYesqNo
AreyoureceivingVAeducationalbenefits?qYesqNo
Areyoucurrentlyenrolledinthehonorsprogram?qYesqNo
Inwhatlanguagesareyourfluent(checkallapplicable)?qEnglishqFrenchqSpanishqOther______________________
Wheredoyouplantoresideattheexchangeschool?qResidencehallqSorority/FraternityqOff-campus
MaritalStatus:qSingleqMarried
Willyoubeaccompaniedonexchangeby:spouseqYesqNo
childrenqYesqNo
Doyouwishtogoonexchangewithanotherstudent(s):qNoqYes:student’sname____________________________________
Nameofcampusatwhichthestudentisenrolled:________________________________________________
Exchange Requests
Periodofrequestedexchange: qFallSemester20____
qSpringSemester20___
qFallQuarter20___
qWinterQuarter20____
qSpringQuarter20_____
qSummer20____
Listinpriorityordertheinstitutionsyouwishtoattendandthetuitionpaymentplan(s)youcoulduse.
NOTE:Costsforroomandmealsarepaidtoyourhostcampusregardlessofwhichtuitionpaymentplanyouselect.
NameofInstitution
TuitionPaymentPlan
PlanA:Youpayresident(in-state/in-province) tuition/feestoyourhostcampus.
PlanB:Youpayyournormaltuition/fees
toyourhomecampus.
1.____________________________________________
___Aonly___Bonly___AorB(prefer___)
qYesqNo
2.____________________________________________
___Aonly___Bonly___AorB(prefer___)
qYesqNo
3.____________________________________________
___Aonly___Bonly___AorB(prefer___)
qYesqNo
4.____________________________________________
___Aonly___Bonly___AorB(prefer___)
qYesqNo
5.____________________________________________
___Aonly___Bonly___AorB(prefer___)
qYesqNo
NSEApplication–page2of5
Ineedclassesinmy
majorwhileonexchange.
Educational Background
Numberofcreditscompletedtodate:_________Numberofcreditsenrolledincurrentterm:_____________
Expectedgraduationdate:__________________
Doyouhaveanyincompletegrades,missinggrades,orotherdeficiencies(e.g.failuretocompleterequired
proficiencytests)?qYesqNo
Ifyes,pleaseexplain:_______________________________________________________________________
Activities,positions,honorswhileincollege:___________________________________________________________
________________________________________________________________________________________________
Special Needs or Circumstances
Ifyouhaveaphysicalconditionforwhichaccessible,on-campushousingorclassroomaccommodationmightbeneeded;a
documenteddisabilitywhichmayrequireacademicaccommodation(e.g.,notetakers,tapedtexts);amedicalconditionwhichmight
requireimmediateattentionduringexchange;oraconditionwhichmightaffectemotionalormentalwell-beingduringexchange,
youareencouragedtoidentifyyourneedsbyattachingaseparatepageindicatingthenatureandextentofyourcircumstancesand
arrangementswhicharecurrentlybeingmadeforyouonthiscampus.Alsoindicatewhetherornotwemaycontactyourrequested
hostcampusesatthistime.
NSEdoesnotdiscriminateonthebasisofspecialneeds.Rather,yourdisclosureatthisstageoftheapplicationprocessisinvitedin
ordertoassistyouinidentifyingaplacementsitewhichcanprovidereasonableaccommodationofyourneeds.Following
placement,itisyourresponsibilitytoconsultthehostcampuscoordinatorandADAofficertodeterminethedeadlinesbywhichyou
mustsubmitwritten,current,andprofessionallydocumentedinformationasrequiredbyyourhostcampus.Writtendocumentation
isusuallyduetothehostcampustwotothreemonthspriortoenrollment.
Other Considerations
Haveyoueverbeenconvictedofafelony?qYesqNo
Areyouonprobation,parole,orhaveanylegaljudgmentspendingagainstyoueitherinsideoroutsidecampus?
qNoqYesIfyes,pleaseexplain:_________________________________________________________________
Areyoucurrentlyunderanycampusdisciplinaryactionforviolationofcodesofacademicorstudentconduct?
qNoqYesIfyes,pleaseexplain:_________________________________________________________________
Doyouhaveanyoutstandingindebtednesstothecampus(tuition,fees,room,meals,libraryorparkingfines)?
qNoqYesIfyes,pleaseexplain:_________________________________________________________________
Language Proficiency
Whatisyournativelanguage?qEnglishqFrenchqSpanishqOther:___________________________________
IfyouplantoexchangetoacampusinPuertoRico,youmustbecertifiedforproficiencyinSpanish.Ifyouplantoexchangetoa
French-speakinguniversityinCanada,youmustbecertifiedforproficiencyinFrench.IfEnglishisnotyourfirstlanguage,forall
otherNSElocationsyoumustdemonstrateproficiencyinEnglish.Languageproficiencymustbedeterminedpriortoplacement.
Recommendations/References
Listtheindividualswhoarewritingreferencesforyou.Submitreferenceformstoyouradvisor,atleastonefaculty/staffmember,
andoneotherpersonwhowillrecommendyouforexchange.
advisor faculty/staff
name department/office
phone e-mail
department/office
phone e-mail
relationshiptoapplicant phone e-mail
NSEApplication–page3of5
Emergency Contact
IdentifyapersonwhoshouldbeinformedincaseofanemergencyatyourhostNSEcampus.
Name_________________________________________________Relationship________________________________
Street_____________________________________________________________________________________________
City,State/Province,andZip/PostalCode________________________________________________________________
Land-linePhone______/___________
CellPhone______/___________E-mail__________________________
Release of Information
Thecollection,retention,anddisseminationofyourrecordsandinformationaboutyouaresubjecttofederalregulationunderthe
FamilyEducationRightsandPrivacyAct(FERPA)of1974.Youareresponsibleforspecifyingthepersonsoragentswhohaveaccess
toyourrecords.Therefore,itisnecessarythatweobtainyourpermissiontorequestandreleaseinformationpertinenttoyour
exchange.Pleasereadthefollowingstatementsandsignbelow:
•
•
•
•
•
Iunderstandthatitwillbenecessaryformycampustoobtaincertaininformationaboutmyacademicandnon-academicrecord
inorderto:1)ascertainmyeligibilityandsuitabilityforanexchangethroughNSE,and2)facilitatemyexchangeafteritis
arranged.IherebygrantpermissiontotheNSEcoordinatorand/ordesigneetoobtaininformationthatisappropriatetomy
applicationandparticipationintheexchangeincluding,butnotlimitedto,lettersofrecommendation,permanentacademic
recordsandtranscripts,conduct,fiscalrecords,medicalrecords,allforthepurposesofexchangeplacementandparticipation,
continuation,ortermination.
IgivepermissiontotheNSEcoordinatorand/ordesigneetocontactappropriatepersonnelinordertoverifythatIamunderno
disciplinaryactionforviolationofcodesofacademicandstudentconduct,Idonothaveanyoutstandingindebtednesstothe
campus,and/orthatIhavenojudicialcasespendingwhichwouldinvalidatemyeligibilityforexchange.
Iherebyreleaseinformationcontainedinmyapplication,lettersofrecommendation,transcripts,andotherinformationrequired
aspartoftheNSEapplicationprocesstomyhomeNSECoordinator,designee,andthoseindividuals/committeesresponsiblefor
reviewingandapprovingmyapplicationforexchangeparticipation.
IherebygivepermissionfortheinformationcontainedinmyapplicationtobesubmittedonNSE’srestricted,Web-based
placementsitefortheuseofthehomeandhostcampusesandtheNSECentralOfficeinplacementandrecord-keeping
processes.
Iherebyreleaseinformationcontainedinmyapplication,lettersofrecommendation,transcripts,andotherinformationrequired
aspartoftheNSEapplicationprocesstotheNSECentralOfficeandtotheNSEhostinstitutionatwhichIamplaced.
Signature_________________________________________________
Supporting Materials or Other Requirements
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•
•
•
•
unofficialtranscript
recommendations/references
programofstudystatement
statementofpersonalgoalsandreasonsforexchangeparticipation
languageproficiencyreport(ifapplicable)
interview
NSEApplication–page4of5
Date____________________________
Signature
Ihavereadandfullyunderstand:
• informationonpages11-24oftheNSEStudentGuide:ExchangePoliciesandProceduresorthesectiononPoliciesandProceduresat
nse.org,Students
• campuspoliciesandproceduresgoverningmyexchangeparticipation
Ifurtherunderstandthat:
• participatingintheNationalStudentExchangeisaprivilegeandnotaright.
• submittinganapplicationisnotaguaranteeofapplicationacceptanceorplacement.
• failuretomaintain(priortoandduringmyexchange)alloftheeligibilityrequirementsoftheprogramandthoseof
myhomeandhostcampuseswillresultinthecancellationofmyexchange.
• failuretomaintainacumulative2.5gpaaswellashavea2.5gpainthetermpriortomyexchangewillresultinthecancellationofmy
exchange.
• failuretopayallfinancialobligationstomyhomeandhostcampuseswillresultinthecancellationofmyexchange.
• untilfinancialobligationsaremet,myhomeandhostcampuseswillnotreleasetranscripts;andIwillnotbepermittedtore-enrollat,
orgraduatefrom,myhomecampus.
• myexchangeisnotcompleteduntilIsubmittomyhomecampusatranscriptofmyhostcampuswork.
IfacceptedforparticipationintheNationalStudentExchange,Iagreetoadheretoalltherulesandregulationsofbothmyhome
andhostinstitutions.Failuretodosowillresultinthecancellationofmyexchange.
Iaffirmthatallinformationiscomplete,accurate,andtruetothebestofmyknowledge.IacknowledgethatIamsigningfreely,
voluntarily,andundernocompulsion.
Signature_______________________________________________ NSEApplication–page5of5
Date_______________________