ESU IN LONDON 2015—PRELIMINARY APPLICATION
Please complete all the sections below and return, along with a deposit of $350 (check only, made out to Emporia
State University with “London Program” in the memo line) to Professor Mel Storm, Department of English, Modern
Languages, and Journalism, by Wednesday, 12 November 2014. (Applications will be reviewed in the order they
are received. The deadline will be extended if the limit of 20 participants is not reached by that date.)
Name: _________________________________ ESU ID# E________________________ GPA _______
Phone: _________________ ESU Email ____________________ Other Email ______________________
Local Address: _________________________________________________________________________
Street
City
State
Zip
Home Address: ________________________________________________________________________
Street
City
Academic major: ________________________
State
Zip
Academic minor: _____________________________
Name of academic advisor: _______________________
Year in school: _________________________
Date of birth: ______ /______________________ / ______
day
month (spell out)
Have you previously traveled abroad?
year
Yes
No
If yes, where/when? _____________________________________________________________________
Do you currently have a passport?
Yes
No (If yes, please make sure your name is entered
above exactly the way it appears on your passport.)
If yes, please list the number and the expiration date. ___________________________________________
Have you studied a foreign language?
Yes
No
If yes, please specify: ___________________________________________________________________
Please list your anticipated sources of funding: Personal savings Family Department/School/College
Student Organization Financial Aid Other grants or scholarships Other (please specify)
______________________________________________________
List two faculty members (university-level instructor or academic advisor) who will serve as references.
(You will need their letters of reference later.)
______________________________________________________________________________________________________
Name
Position
Department
______________________________________________________________________________________________________
Name
Position
Department
If you have questions, please contact Professor Mel Storm, Department of English, Modern Languages, and Journalism: Phone
620-341-5563; Email mstorm@emporia.edu; Fax 620-341-5547
Date/time received ________________________________