PAGE 1
INT’L PROGRAMS OFFICE USE ONLY:
Date received: _________ Completed:_________
Notes: __________________________________
_________________________________________
CSU CHANNEL ISLANDS STUDENT EXCHANGE APPLICATION FOR:
Term(s) of study on exchange:
Fall semester
Planned Period of Study on Exchange:
Spring semester
From:
To:
Month / Year
I.
Month / Year
APPLICANT INFORMATION
INSTRUCTIONS: Pages 1 and 2 of this application MUST BE TYPED. Keep a copy of your completed application for your records,
A.
PERSONAL INFORMATION
1. Are you a US citizen by birth or after
birth through parents or naturalization?
Yes:
If yes, do not proceed. US citizens are not eligible for this exchange.
If no, please proceed with completing this application.
No:
2. Applicant’s Legal Name:
(as it appears in your passport)
Family/Surname (Last) Name
Given (First) Name
3. Date of Birth:
Middle Name
4. Gender:
Month
/
Day
/
Female:
Male:
Year
5. Place of Birth:
City
State/Province
6. Country of Citizenship:
8. Addresses
Country
7. Country of Permanent Residence:
Current Address
Permanent Address
Valid from:
Until:
Month/Year
(If different than your current address)
Month/Year
Street and Apartment #:
City:
Province/State:
Country and Postal Code:
Telephone Number:
Country Code
City Code
Number
Country Code
City Code
Number
9. Email Addresses:
Preferred Email Address
Alternate Email Address
B. ACADEMIC INFORMATION
10. Applicant’s Home University:
11. Field(s) of Study at Home Institution:
12. Principle Field(s) of Study during Exchange:
13. If available, are you interested in applying for on-campus housing?
14. Class Level during Exchange:
2nd Year UG:
Yes:
No:
3rd Year UG:
4th Year UG:
Note: UG = Undergraduate Student
15. Tertiary Institutions/Universities Attending or Attended
Name of Institution
Enrollment Dates
Start / End
Name of Degree Received or In-Progress
Example: BA – English (in progress)
Student’s Family (Last) Name, First
CSUCI STUDENT EXCHANGE APPLICATION FOR:
PAGE 2
Student’s Family (Last) Name, First
VERIFICATION OF FINANCIAL SUPPORT
All exchange student applicants are required to complete Section A below and submit this form with their exchange application
to show that they have access to $10,000 per term.
To verify that you have funds available to you while on exchange, you must provide official bank documentation, which shows
that you and/or your sponsor(s) have the minimum required amount of financial assets available to you while on exchange.
Bank statements must be recent. It is recommended that you show funds in excess of the amounts shown since exchange rates
can vary.
Due to exchange rate fluctuations and cost of living increases in California, it is advisable to provide more funding that the
required amounts listed above.
A. Sources and amounts of financial support available while studying at CSU
In National Currency
Your own funds:
Funds from sponsoring parents, friends, relatives:
Government scholarship or sponsoring agency:
Total amount:
Month / Day / Year
If you will use a sponsor to satisfy this financial obligation, then your sponsor must either sign below under Certification of
Financial Sponsor or provide a letter declaring their relationship to the student and their intent to provide financial support
throughout the student’s period of study at CSU Channel Islands. If more than one sponsor will provide financial support, each
sponsor must provide a separate letter declaring intent to sponsor. Each sponsor must provide a signed bank statement or a
letter from their bank showing the availability of the necessary funds.
B. Certification of Financial Sponsor (or provide letter from your sponsor)
"I guarantee that $______________ (in U.S dollars) will be available to the above-named student for his/her study at the CSU."
Name of sponsor:
Address of sponsor:
Relationship to student:
Sponsor's signature:
Date:
Month / Day / Year
C. Verification by Bank Official (or provide a letter from your bank or provide bank statements)
"I certify that ________________________________ has deposited in this bank the equivalent of (U.S. dollars) $
Given (first) name Surname/family name
Name and position of bank official:
Name and address of bank:
Bank stamp or seal:
Signature of bank of official:
Date:
Month / Day / Year
."
CSUCI STUDENT EXCHANGE APPLICATION FOR:
III.
Student Name:
PAGE 3
ENGLISH LANGUAGE PROFICIENCY
Applicants (including students studying at institutions in Australia, Canada and the UK) who have not attended an education
institution at the secondary level or beyond where English is the principal language of instruction for at least three years are
required to take ETS TOEFL Test (Test of English as a Foreign Language) or the IELTS (International English Language
Testing System) or submit DAAD scores. Original test scores must be submitted with this application.
 61: ETS TOEFL (internet-based score)
 6.0 IELTS
 DAAD: B or better
IV.
HEALTH INSURANCE
International students are required to purchase and maintain health insurance through the CSU Wells Fargo Healthlink:
https://www.csuhealthlink.com/enroll/ . Students must purchase this specific insurance, regardless of what insurance students may
already have. Exchange students will also receive information about health insurance requirements once accepted. Proof of health
insurance must be submitted at least one month prior to program start date. Failure to purchase the Wells Fargo Healthlink
insurance will result in the student’s admittance status being terminated.
V.
STATEMENT OF UNDERSTANDING
I understand and agree that if I am admitted to CSU Channel Islands (CI) as an international exchange student that:
 I will take part in exchange program-related activities at CI including attending the mandatory orientation session for
international exchange students before the semester begins. I understand that I am considered a representative of my
home country and university and that my active participation at CI is essential to the sustainability of the exchange
program.
 I must be flexible in the selection and scheduling of courses (subjects) that I wish to take. I understand that enrollment of
specific courses are not guaranteed. I must also not expect to take subjects in areas of study which are impacted.
 I am required to maintain good academic standing and to register in and maintain full-time enrollment each term.
 I have the necessary funds to support me for the length of my exchange as reflected in the amounts disclosed in Page 2
of the Application: Verification of Financial Support. While the CI tuition fees are waived for exchange students, I am
required to pay other costs that I incur at my host campus by the deadline date(s) given to me pertaining but not
limited to the following: housing, transportation, student ID card, phone usage, utilities, textbooks, health services,
student activities.
 I must purchase and maintain health insurance (as indicated in Section IV) for myself.
 I must obey the regulations and policies of my host university as well as the laws of the State of California and the USA.
Student Signature:
Date:
Month / Day / Year
VI.
SUBMISSION OF APPLICATION
Submit the original application plus the following forms and documents to the Exchange Coordinator at your home institution.
 Verification of Financial Support and supporting documents. See form (SUP A) following this page.
 Copy of the page of your passport showing your photo, full legal name and place of birth.
 Original TOEFL, IELTS, or DAAD test results (if applicable).
 Official transcripts of ALL tertiary/university study listed on page 1 (Question 15)
Your application cannot be considered without the above items. If you are admitted to CI, International Programs the office will
issue a letter of admission and a DS-2019 (Certificate of Eligibility for Exchange Visitor Status) which will be forwarded to your home
university Exchange Coordinator. The DS-2019 from the CI enables you to apply for the J-1 visa. Do not plan on leaving your
country of residence until you have been issued the visa; it will allow you to enter the United States 30 days before the program
start date.
VII. HOME INSTITUTION ENDORSEMENT (to be completed by your Exchange Coordinator)
I verify that the student will be enrolled in a degree program at his/her home institution during the proposed period of exchange.
I have verified that the student is submitting a completed application which includes the documents listed in Section VI. After
reviewing the student’s application, I recommend the student’s participation in this exchange.
Printed Name:
Signature:
Title of Position:
Date:
Month / Day / Year
[03/09/15]