Office of International Programs
400 Culbertson Hall
Bozeman MT 59717-2260
Tel:
+1 (406) 994-7512
Fax: +1 (406) 994-1619
Please type or print
Application for Special Short-term Study Abroad Programs
Student ID#:
Personal Information (print clearly)
Program applying for:
Name:
E-mail:
SS#:
Permanent Address:
City:
State:
Zip:
Local Address:
City:
State:
Zip:
Local Phone:
Are you a U.S. Citizen?:
Yes
No
Birth date:
Sex:
Male
Do you have a U.S. Passport?:
Yes
No
Female
Passport Number:
Passport Expiration Date:
If you hold a non-U.S. passport, which country is it from?:
Please list the name, relationship, and phone number of 3 references:
1.
2.
3.
Emergency Contact Information
Name (and relationship):
Home Phone:
Email:
Work Phone:
City
Address:
State:
Zip:
:
Academic Information
Academic Status:
Major(s):
Undergraduate
Graduate
Non-Degree
Year in School:
1
Minor(s):
Briefly explain what you hope to achieve in this program both academically and personally :
2
3
4
Grad N/A
(Please be sure to read and sign the reverse side)
For our records
How did you hear about this program?
Signature and Verification
Your signature verifies the following:
1. I have completed the necessary prerequisites to enroll in this program.
2. International Education programs require that participants are in good academic and
disciplinary standing at the university and I authorize the Office of International Programs at
Montana State University access to my academic and disciplinary records.
Signature of Applicant:
Date:
Deposit Received:
This application must be completed and returned
along with a $200 deposit to:
NOTE: Deposits are refundable if student is not accepted into the program. Unfortunately,
MSU Office of International Programs cannot take credit cards at this time.
Kevin Brustuen
Office of International Programs
406 Culbertson Hall
Bozeman, MT 59717-0226
Phone: (406) 994-7512
Fax:
(406) 994-1619
kevin.brustuen@montana.edu