“International Student Packet”
Thank you for your interest in Housatonic Community College. This is our “International Student Packet”
This serves as a guide to help you when completing information necessary for fulfilling our international student
admission requirements from items 1 to 11. Please see the 2014-2015 College Catalogs for Admission of
International Students on pages 10-11.
FALL 2015 SEMESTER DEADLINE: Friday, June 26, 2015
“ALL” international student packet requirements below must be submitted by above
deadline.
Fall 2015 Semester Classes start on Monday, August, 31, 2015
**All tuition and fees are subject to change**
1.
Complete the International Student Information form for SEVIS registration on page 4.
2.
A certificate of English Proficiency (T.O.E.F.L.) exam is required of all applicants whose dominant language is not
English. This means if you are not from an English speaking country you need to take the TOEFL. This certificate may be
obtained from an American Consulate in the applicant’s homeland. English Literacy: Evidence of ability to read, write and
speak English is required for acceptance at this college. For additional information: www.toefl.org. The TOEFL can only
be waived: (1) If you are from an English speaking country, (2) Graduated from a U.S. high school or (3) completed a U.S.
Advanced Level ESL Program (English as a second language). TOEFL results may take up to more than 6 months so
please plan ahead. A minimum score of 173 on the computer based test, 61 on the internet based test, or 500 on the
paper based test is required.
3.
Complete our Admissions application (Student Data Sheet). Return this application (along with all other international
student requirements) to our Admissions Office. **Don’t forget to include the country where you were born and the
permanent address in your home country. Mailing address is your residence in Connecticut whereas your permanent
residence is in your home country. The application must be completed in full with the CT address you intend to. In order to
pursue a full course of study, you must enroll in a degree program. You may add a certificate program as a secondary or
minor major.
4.
Include $20.00 non-refundable application fee. (Make check /money order payable to Housatonic Community College.)
5.
Proof of Measles, Rubella and Varicella (MMRV) immunization. (See attached form on page 10-11).
6.
You are also required to include a copy of your HIGH SCHOOL DIPLOMA or OFFICIAL HIGH SCHOOL
TRANSCRIPTS. High School Diplomas (only) can be submitted in another language. Official transcripts must be in
English showing your academic course work completed at your high school and each college where applicable. (Official
transcripts-all course work- must be translated into ENGLISH in order to be evaluated.) These credentials are evaluated in
accordance with the college’s general admissions requirements. Foreign college credits must be evaluated by accredited
agencies such as World Educational Services (www.wes.org ), Center for Educational Documentation
(www.cedevaluations.com), Globe Languages Services Inc. (www.globelanguage.com).
7.
A (NOTARIZED) letter of residence must be submitted stating your local residential address you intend to reside in
Connecticut while attending Housatonic. (See attached form, page 7). NOTE: This is a commuter school; there are no
housing facilities for students.
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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8.
FINAICIAL RESONSIBLITY. The prospective international student, relative or sponsor must provide a (NOTARIZED)
“Sponsor’s Financial Affidavit Letter. A letter stating “who” will be responsible for your total college expenses of
$36,816.00. (Funding must be available to cover the cost of all school and living expenses during the entire period of
anticipated study in the U.S.). NOTE: This is a commuter school; there are no housing facilities for students.
9.
FINANCIAL PROOF: All visa/I-20 applicants must provide that they have sufficient readily available and accessible
funds to meet all expenses for the first year of study of $18, 408.00, including the tuition, fees, books, and estimate
living expenses. In addition, applicants must also provide proof of adequate funds for each subsequent year
to cover the remaining of their studies.
Referring to #8, whom ever is responsible for the applicant’s college expenses must provide “financial proof” showing they are
able to do this. Applicants must demonstrate that they have sufficient funds from an identified and reliable financial source.
All financial documents must be in liquid or cash value and easily converted assets. All financial documents must be
current within 3 months and converted in the U.S. currency. Please see page 8.
10. Copy of Current PASSPORT/I-94 CARD (only for students who have a passport. You must bring to Admissions. You may
download your copy of I-94 card from online. Please visit this website, http://www.cbp.gov/travel/international-visitors/i94-instructions
11. Complete the I-901 form and send $200.00 fee for Student/Exchange Visitor Processing Fee. New students need to
complete this form. Transfer Students do not need to complete this form). You may download the form from the
http://www.ice.gov/sevis/i901/ or visit the college website. http://www.hcc.commnet.edu/admissions/index.asp .
You need to put the School Code: BOS214F10372000 on Number 14.
NOTE: In order for the DSO to issue a Form I-20, applicants must meet the international student
admission requirements.
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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Dear Students:
The USCIS has made recent changes in the record keeping of International Students. This letter will update you as to your
duties and obligations under these changes. We also wish to remind you that:
1) You are responsible for maintaining your F-1 status. If you are not registered as a full-time student you may lose your F-1
Status.
2) You must maintain your Passport, I-20, and I-94. Staple your I-94 to your passport. You must have all three when traveling.
3) You must see the Designated School Officials (DSO), Ms. Ratanavong, before you leave the country. Be sure the back of
your I-20 is signed every six months by a Housatonic Community College Designated School Official (DSO) before leaving the
United States.
4) If your passport has expired, go to your embassy or consulate in the New York City to extend your passport.
5) You cannot skip a semester; you must remain enrolled in each of the semesters.
6) You must notify us when you change your HCC program or major.
7). You must notify the DSO if you’re applying for practical training (Practicum, experiential learning, or internship).
For post-completion OPT, you can file the Form I-765 up to 90 days before your program end date and no later than 60
days after your program end date. This is your responsibility to inform the DSO.
8) You must notify the Admissions Office or DSO, Registrar’s Office and the USCIS when you change your local address.
http://www.uscis.gov/addresschange
9) You must notify the Admission Office or DSO 60 days prior to the expiration of your I-20 if you plan to request a program
extension.
10) You will need authorization by the USCIS to work while in the United States.
11) You must apply for graduation evaluation if you have completed more than 30 credits.
12) It is mandatory for all F1 students to attend International Student Workshops, Orientations, and Advising sessions.
13) If you have academic difficulty or medical illness, please notify PDSO or DSO in Admissions Office. Only PDSO or DSO
is authorized to reduce your course load not your professors or academic advisors.
14) All HCC enrolled students are eligible to enroll in the Injury and Sickness Plan on a voluntary basis. You may purchase a
medical insurance coverage through an independent agency or the Student Injury and Sickness Insurance Plan for Connecticut
Community Technical Colleges at an additional expense to you. This is your responsibility, not the college. For more
information on, please visit http://www.hcc.commnet.edu/resources/insurance/index.asp.
Please sign stating that you have read and understand your duties and obligations as an F-1 Student.
Name:______________________________
______________________________
Signature
Banner ID ( if known)____________________________
_________________
Date
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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OFFICE USE ONLY
SEVIS Number:_________________
BANNER ID: __________________
International Student Information Registration Sheet
PLEASE PRINT CLEARLY
FULL NAME: Mr. /Ms________________________ ____________________
Last (family name)
First
_______________
Middle
Date of Birth ____________ Male____ Female____ Social Security No ( If applicable). ________/______/________
Major/Program:___________________________
Country of Birth: _____________________________ Country of Citizenship___________________
U.S. Driver’s License Number: (If applicable)________________________ Driver’s License State Issue: ______
ADDRESS IN HOME COUNTRY:
Please provide a complete address.
Street Address___________________________________________________________________
City ___________________________ Province/Territory_____________ Telephone_____________________
Postal Code____________
Country __________________________________
ADDRESS IN UNITED STATES:
Street Address: _________________________________________________
City_________________ State______ Zip Code_______ Home phone #______________Cell #_____________
EMAIL ADDRESS: _____________________________________________________________
PERSON TO CONTACT IN CASE OF EMERGENCY:
Name: ________________________________________________ Relationship:_____________
Address:____________________________________________Telephone#_____________________
DEPENDENT(S): (Spouse & children only): If more than 1 dependent, please list their information on the back of this sheet.)
FULL NAME: ________________________ ____________________ _______________
Last (family name)
First
Middle
Date of Birth ____________ Male____ Female____ Relationship: __________________
Country of Birth: _________________________ Country of Citizenship___________________
Passport NO:_________________________ Expiration Date;___________________ I 94 Card NO:__________________
IMMIGRATION INFORMATION
Visa Classification/Current Visa Status (Please check one)
q F-1 visa Admission Number (11 digit from I-94):____________________________________
q
J-1 Program Visa Sponsor -Section 2 of your Form DS2019-(Formerly
IAP-66)___________Program#:___________
DS2019 Expiration Date:__________Subject to 2 yr. Residence ( see visa page)______ Yes
Form
NO_______
q
Other Visa (B1/B2, F2, H4, please specify) :______________ Apply for a change of Status:_____________
q
Passport Number: ___________________________ Expiration Date of Passport:___________
Expiration Date of US Entry Visa: _________________ Expiration Date of Form I-94:___________
Expiration Date of Form I-20 (number 5 on the form I-20):__________________ Date of U.S. Port of Entry__________
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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IMPORTANT
Please submit requirements early to allow enough time for the foreign student advisor to review your
mandatory requirements in order to advise the applicant of any items still missing or necessary changes that
need to be made.
“All” requirements must be submitted in order for the student advisor to issue the applicant a complete I-20
form for their F-1 (International Student) visa. There will be no exceptions; all requirements must be
submitted to receive an I-20 form. This I-20 Form (F-1 status) is required by the United States Immigration
Office in order to study at Housatonic full time. The I-20 is only issued to students who submit all
requirements. I-20 applicants are accepted as FULL TIME students in a DEGREE program and must
remain in good academic standing.
Visa regulations allow you to enter the United States up to 30 days before the first day of classes (the reporting date shown
on your I-20). If you attempt to enter the U.S. earlier, you will be denied entry at the airport immigration area.
***THE COLLEGE CANNOT PROVIDE INTERNATIONAL STUDENTS WITH ANY FORM OF FINANCIAL
ASSISTANCE (FINANCIAL AID). (You are responsible for providing all of your own college expenses.)
Check list summary of all required items you are responsible for providing:
1.
2.
3.
4.
5.
6.
7.
8.
9.
_____ International Student Information form for SEVIS registration.
_____ T.O.E.F.L. TEST RESULTS (UNLESS STUDENT IS FROM ENGLISH SPEAKING COUNTRY)
_____ Admissions Application
_____ $20.00 APPLICATION FEE
_____ PROOF OF MEASLES, RUBELLA and VARICELLA (MMRV) IMMUNIZATION
_____ ALL HIGH SCHOOL/COLLEGE RECORDS IN ENGLISH
_____ (NOTARIZED) RESIDENCE LETTER (SEE ATTACHED FORM)
_____ (NOTARIZED) AFFIDAVIT LETTER FOR FINANCIAL RESPONSIBILITY of $36,816.00
_____FINANCIAL PROOF (notarized financial documents ) available and accessible funds to meet all expenses for the
first year of study, including the tuition, fees, books, and estimate living expenses.
10. _____ TRANSFER SEVIS I-20 RELEASE FORM FOR TRANSFER STUDENTS ONLY
11. ____ COPY OF CURRENT PASSPORT/I-94 CAR. Must bring original passport and Admissions will make copies of
front and back)
12. _____ Complete the I-901 form for SEVIS application and send $200.00 fee to USCIS.*** (transfer students do not need to
complete this form). The school code : BOS214F10372000 . Please download the I-901 form at one of these
websites: http://www.hcc.commnet.edu/admissions/index.asp or http://www.ice.gov/sevis/i901/
Issuance of I-20
Once all requirements are submitted on time and reviewed, the College will issue the student the I-20, “Certificate of
eligibility for Non-Immigrant “F” Student Status.” This form will be forwarded to your attention. If you are applying from
overseas, please be aware that you will need to sign this form at the American Embassy in your country, in front of them, to
approve your F-1 visa status. You may be refused entry into the United States if you attempt to arrive more than 30 days
before the program start date listed on your SEVIS I-20 form. You should report to their school within 30 days of the
date that appears on the SEVIS I-20 form to register for courses or to validate your intended participation. Failure to do
so may result in serious consequences. You will not be allowed to enroll in classes if you fail to report to Housatonic
Admission Office by the date on your I-20 form! No exceptions. Failure to report to Housatonic will result in your name being
reported to the USCIS as “Out of Status”, at their request.
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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IMPORTANT NOTICE:
Enrollment in a course of study is prohibited for B1 and B2 visas.
An alien who is admitted as, or changes status to, a B-1 or B-2 nonimmigrant on or after April
12, 2002, or who files a request to extend the period of authorized stay in B-1 or B-2
nonimmigrant status on or after such date, violates the conditions of his or her B-1 or B-2
status if the alien enrolls in a course of study. Such an alien who desires to enroll in a course of
study must either obtain an F-1 or M-1 nonimmigrant visa from a consular officer abroad and
seek readmission to the United States, or apply for and obtain a change of status under section
248 of the Act and 8 CFR part 248. The alien may not enroll in the course of study until the
Service has admitted the alien as an F-1 or M-1 nonimmigrant or has approved the alien's
application under part 248 of this chapter and changed the alien's status to that of an F-1 or
M-1 nonimmigrant. (Added 4/12/02; 67 FR 18062)
A B visitor who begins a course of study prior to the approval of a change of status application
is considered to have violated a condition of his or her immigration status. USCIS will deny a
change of status request if the B-1 or B-2 nonimmigrant enrolled in a course of study before
filing the application for change of status or while the application is pending before the
USCIS.
Study restrictions: B1/B2 VISAS
A B1/B2 visa holder cannot begin a course of study or student employment until his or her
application for a change of status to F-1, M-1, or J-1 is approved. This is a change in policy
and B-2 visa holders must be careful not to begin a course of study that is unauthorized.
“A course of study” is considered to be a focused program of classes, such as a full-time course
load leading to a degree or certification. Casual, short-term classes that are not the primary
purpose of the visitor’s presence in the United States, such as a single English language class
would not constitute ‘a course of study’ [INS Field Memorandum, April 12, 2002].
A B1/B2 visa holder may engage in part-time study incidental to visit - e.g., may enroll in
short-term English language or recreational courses such as crafts class.
NOTE***Please notify us if you are considering to apply for change of status. We have the Change of Status
application available in Admissions Office.
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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LETTER OF RESIDENCE
(Must be notarized)
This letter is to certify that __________________________________________ of
(Student Name)
__________________________ __________________________ will be living
(Country of Citizenship)
(Country of Birth)
with me in my home at the following address until his/her studies are completed at
Housatonic Community College.
THIS MUST BE A CONNECTICUT ADDRESS:.
Name
_____________________________________________________
Street Address: _________________________________________________
City_________________ State______ Zip Code_______ Home phone #______________Cell #_____________
HOME COUNTRY ADDRESS: The Address Must be a Complete Address.
Name
_____________________________________________________
Street Address___________________________________________________________________
City ___________________________ Province/Territory_____________
Postal Code____________
Country __________________________________
Telephone and Country Code: _____________________
Signed _____________________________________________________
Date
_____________________________________________________
(Needs to be Notarized
By Notary Public)
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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Fall 2015 Mandated Estimate College Tuition for International Students
Tuition & Fees
One Year
(2 semesters)
(x2)
Two Years
(4 semesters)
Tuition
College Service Fees
Student Activities Fees
$10, 296 .00
$1, 242.00
$20.00
X2
$20,592.00
$2, 484. 00
$ 40.00
One Year
$ 11, 558.00
Two Years
$ 23,116.00
Tuition & fees listed above are approved by the Board of Regents for Connecticut Community Colleges. These
costs may increase at any time, and you will be billed for any increase accordingly.
**Note: Acceptable proof of financial responsibility:
• Readily available and accessible funds for the first year must be $18, 408.00
• Applicants must also provide proof of adequate funds for each subsequent year to cover the remaining
of their studies.
a.
b.
c.
d.
e.
Current official bank statements within 3-6 months.
Letter of employment verification from sponsor (s).
Current payroll stubs from the employer within 3-6 months.
Copy of current tax returns from sponsors (s).
Reliable financial funding source in liquid or cash value: scholarship, free room and board, student loans.
HCC will not accept financial documents from investments such as retirement accounts, mutual funds, stocks, bonds,
commodity trading accounts, property deeds, etc.
♦ Full tuition & fees “must” be paid at time of registration for “each” semester.
♦ Refer to the attached “Out of State” tuition and fee cost sheet
♦ All International students (F-1) are considered “Non Residents. It means that you will pay Out of State Tuition”,
even if you have resided in Connecticut for over 1 year.
♦ All International Students “must” remain full time status (12 credits or more/4 courses or more)
♦ Payment plan is available. See the Bursar’s Office for the application and instructions.
♦ All tuition and fees are subject to change without notice.
In addition to the above tuition and fees, USCIS mandates Living expenses as well to provide appropriate housing,
food, clothes, etc. for all International Students. (These estimates below do not need to be paid at time of registration;
Fall 2015 Semester Estimate College Tuition, Fees & Living Expenses:
1 Year
Living Expenses (1 year)
$6,250.00
Total Living Expenses (2years)
(x2)
Books (1year)
$ 600.00
Books (2 years)
(x2)
Tuition and Fees= 1 year
$11,558.00
Tuition and Fees = (2 years)
*Grand Total Tuition, Fees, books, & Living Expenses =
$18,408.00
2 Years
$ 12,500.00
$1,200.00
$23, 116.00
$36,816.00
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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(Example)
“Sponsor’s Financial Affidavit Letter”
Must be Notarized
This letter is to certify that I, _________________________________________________ will be
(Sponsor’s name)
responsible for ____________________________________________ ‘s total college expenses of
$36,816.00 while pursuing a college degree at Housatonic Community College.
Sponsor’s Signature _______________________________________ Date___________________
(Notarization)
---------------------------------------------------------------------------------------------------------------------------MORE THAN ONE SPONSOR?
Affidavit Letter: If there’s more than one sponsor for the student, each sponsor’s name must be stated on the
letter as responsible for the $36,816.00 (tuition, fees, & living expenses) and notarized. (Treated just like cosigning a contract). Each sponsor needs to complete this form separately.
Each sponsor can submit his/her own proof of financial support. Funding must be available to cover the cost of
all school and living expenses during the entire period of anticipated study in the U.S.
This is USCIS regulations and Housatonic Community College policies. USCIS mandates proof that the student be
provided with a shelter, clothes, food and their college expenses paid for.
All International Students (F-1, status visas) must pay “Out of State” ( NON RESIDENT ) tuition and college fees.
(See attached form) This is true even if the student has lived here in Connecticut for years. Once the student registers
and enrolls in classes full time, the college tuition and fees for that semester must be paid immediately. Each
semester, full time, will be approximately $5,779.00
(Needs to be Notarized by Notary Public)
****NOTE****All tuition and fees are subject to change without notice.
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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State Immunization Policy
BANNER ID#
If unknown, leave blank
900 Lafayette Blvd. Bridgeport, CT 06604
Students must return this completed document to the Admissions Office or the Health Records Office prior to registration.
If you were born after December 31, 1956, Connecticut State Law requires that all full-time (degree seeking and nondegree/non-matriculating) and part-time matriculating students enrolled in postsecondary schools be adequately protected
against measles, mumps and rubella. In addition, beginning on August 1, 2010 all full-time and matriculating
students, except those born in the continental United States prior to January 1, 1980, must provide proof of
immunization against varicella (chicken pox). Students must have two (2) doses of each vaccine administered at least
one (1) month apart to insure adequate immunization.
If you are not exempt, please complete one of the options below and attach the necessary documentation.
First Name
Last Name
SS#
-
Date of Birth
-
/
Middle
/
Address
Street
Town
State
Zip
Graduation Year
High School
New
Transfer
Continuing
OPTION 1: RECORD OF IMMUNIZATION
This section must be completed by either a physician or someone operating under the direction of a physician (ex. School
nurse, physician’s assistant, or nurse practitioner).
Vaccination
Type
Measles
1st
Dose
mo/day/yr
/
Mumps
mo/day/yr
/
Rubella
/
/
mo/day/yr
/
/
Date of Test
/
/
Date of
Disease
/
mo/day/yr
mo/day/yr
/
/
/
mo/day/yr
mo/day/yr
/
Result of
Test
mo/day/yr
mo/day/yr
/
OPTION 2: LAB EVIDENCE OF IMMUNITY
OR CONFIRMED CASE OF DISEASE
Test results (Titer) for lab evidence must be attached
to this
form or document that you have already had the disease(s). If
you cannot document a confirmed case of the disease(s), then
you must submit immunity results from a medical laboratory.
2nd
Dose
/
Readmit
/
/
/
OR
MMR
mo/day/yr
/
/
mo/day/yr
mo/day/yr
/
/
/
/
AND
Varicella
(Born after
1/1/1980)
Enter on Banner
mo/day/yr
/
/
Hold Removed
mo/day/yr
/
mo/day/yr
/
/
Reviewed
/
Letter Sent
Letter Sent On
Health Records Fax (203) 332-5063
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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Immunization waivers
OPTION 1 & 2: This must be completed by your physician. I hereby certify that this student
has received the immunization(s) or has laboratory evidence of immunity as indicated.
Signature of physician or authorized person
Date
Physician’s stamp or DEA number
OPTION 3: MEDICAL EXEMPTION
Students with medical exemptions shall be permitted to attend college except in the case of a vaccine-preventable disease
outbreak in the college. All susceptible students will be excluded from college based on public health officials’ determination
that the college is a primary site for disease exposure, transmission and spread into the community. Students excluded from
college for this reason will not be able to return to school until:
1. the danger of the outbreak has passed as determined by public health officials
2. the student becomes ill with the disease and completely recovers, or
3. the student is immunized.
For example, for measles, the complete incubation period is 18 days from the onset of symptoms for the last case in the
community. Outbreaks like measles may last for several months.
According to State statutes, (Connecticut General Statues Sections 19a-7f and 10-204a) no student may be admitted to
school without proof of immunization or a statement of exemption. Students seeking an exemption on the basis that a given
immunization is medically contraindicated should attach a statement to the form signed by their physician stating that in the
physician’s opinion, such immunization is medically contraindicated and why it is contraindicated (ex. hypersensitivity to a
vaccine component, demonstrated reaction to vaccine etc.) In addition, the student should complete the following statement
and return it to the HCC Admissions Office (LH-A106) or Health Records Office (LH-A113).
I am submitting the enclosed documentation from a physician that immunization is medically contraindicated. Therefore, I am
exempt from receiving the required immunization as specified by the physician, and shall be permitted to attend college
except in the case of a vaccine-preventable disease outbreak in the school.
Student Name
Student Signature
OPTION 4: RELIGIOUS EXEMPTION
Students with religious exemptions shall be permitted to attend college except in the case of a vaccine-preventable disease
outbreak in the college. All susceptible students will be excluded from college based on public health officials’ determination
that the college is a primary site for disease exposure, transmission and spread into the community. Students excluded from
college for this reason will not be able to return to school until:
1. the danger of the outbreak has passed as determined by public health officials
2. the student becomes ill with the disease and completely recovers, or
3. the student is immunized.
For example, for measles, the complete incubation period is 18 days from the onset of symptoms for the last case in the
community. Outbreaks like measles may last for several months.
According to State statutes, (Connecticut General Statues Sections 19a-7f and 10-204a) no student may be admitted to
school without proof of immunization or a statement of exemption. Students seeking an exemption on the basis that
immunizations would be contrary to their religious beliefs should complete the following statement and return it to the HCC
Admissions Office (LH-A106).
I hereby assert that immunizations would be contrary to my religious beliefs. Therefore, I am exempt from receiving the
required immunization under Section 10-201a of the Connecticut General Statutes and shall be permitted to attend college
except in the case of a vaccine-preventable disease outbreak in the school.
Student Name
Student Signature
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
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International Student SEVIS I-20 Record Release Transfer Form
FOR TRANSFER F-1 VISA STUDENTS ONLY
900 Lafayette Boulevard, Bridgeport, CT 06604
http://www.hcc.commnet.edu
Phone: 203-332-5100
Fax 1-203-332-5294
School Code: BOS214F10372000
SECTION I – TO BE COMPLETED BY STUDENT
You should not have your SEVIS record released to Housatonic until you have been accepted to HCC. Upon
acceptance, please provide the International Student Advisor of your previous school with a copy of Housatonic
Community College‘s acceptance letter in order to request that your SEVIS record be released to HCC. **Transfer
students must maintain their visa status at the current school prior to transferring to HCC.
Name of Student _________________________________________________________________________________
Last Name
First Name
Middle
Semester for which you are applying to HCC: Fall ___________
Spring ____________
Degree program you are applying for ___________________________ of Associate Degree
Social Security Number ___________________________ Country of Citizenship _________________________
I hereby grant permission for the information requested below to be made available to Housatonic Community College.
________________________________
Student’s Signature
___________________________
Date of Birth (mm/dd/yy)
_______________________
Date
SECTION II – TO BE COMPLETED BY THE INTERNATIONAL OFFICE
The student named above has applied to the Housatonic Community College for the term above. We are requesting the following
information so that we may determine the student’s eligibility for transfer according to Title 8 CFR 214.2 (F) (8) (ii). Please return this form
to the mailing address above:
Institution Name: _________________________________________________________________________________
Address: ________________________________________________________________________________________
Student’s I-94 Admission number: ____________________________ SEVIS Number #: N______________________
Enrollment Dates: Beginning Date (Semester/Year):______________________________________________________
Date of Intended Transfer: __________________________________________________________
(mm/dd/yy)
Please check appropriate statement:
1. ____ Out of Status. Semester last enrolled was ________________________________________________________
2. ____ Approved for OPT or CPT from ______________________to _________________
3. What is the expected date or last date for completion of studies in student’s current degree program? _____________________
4. What is the level of education the student last pursued? _________________________________________________
5. Is he/she considered to be pursuing a full course of study and maintaining F-1 Status? ________________________
6. Has the student met all the financial obligations? _____________________________________________________
7. TRANSFER APPROVED
________ YES
________ NO
8. If no, state reason _____________________________________________________________
9. Comments: ____________________________________________________________________________________
10. Has the student been released in SEVIS?
Yes _____ No ____
Date:______
(Please do not release the student’s SEVIS record until student has been accepted at Housatonic Community College).
________________________________
Title:_____________________ Phone: ______________________Fax::___________________________
Name & Title of Designated School Official completing this Form
Signature __________________________________
Date _________________
12
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
CONTRACT FOR F1 STUDENTS
After receiving the Housatonic Community College I-20, you are required
to take the Institutional Placement Test 2 to 3 weeks prior to the 1st day of class.
Student’s
Initials
* You must be in Full-time status (12 credits or more).
* It is your responsibility to comply with all immigration regulations
which apply to F-1 students.
* STUDENTS (NOT SPONSORS) ARE RESPONSIBLE FOR OUT OF STATE
TUITION PAYMENT.
*You may purchase a medical insurance coverage through an independent agency or the
Student Injury and Sickness Insurance Plan for Connecticut Community Technical Colleges at
an additional expense to you. This is your responsibility, and not the college.
I understand that I must pay tuition in full at time of registration or apply for the
3-way payment plan at least 3 weeks prior to the 1st day of school.
I promise to make full payment in accordance with the payment amounts in the agreement. I understand
that if I fail to meet the full payment indicated, I will be withdrawn from the College but continue to be
responsible for the entire amount. I also understand that once I have been withdrawn from the college, I will
be responsible for any additional fees associated with re-instating me back into my classes and for possible
losing my F-1 status. I acknowledge that I have received the Student’s Copy as my official copy of this
agreement, have reviewed and understood the policies and procedures covering the requirements, have
accepted its term, and no future reminders need to be issued.
__________________________________________
Full Name
___________________________
Date
__________________________________________
Student Signature
___________________________
Date
__________________________________________
P/DSO
___________________________
Date
13
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
This form is to be completed by the Designated School Official (DSO).
_______
Name:________________
Last Name
Middle
First
Initial/New: ________
Transfer from:___________________
SEVIS Number: ___N_______________________
BANNER ID: @______________________
CHECKLIST” OF INTERNATIONAL STUDENT REQUIREMENTS
1. ____ T.O.E.F.L. Test Results (unless student is from an English Speaking Country)
2. ____ International Student Information form for SEVIS registration.
3. ____ Admissions Application
4. ____ $20.00 Application Fee ( Money Or Check)
5. ____ MMRV: Proof of Measles, Rubella Immunization and Varicella
6. ____ High School/Secondary School Proof: Diploma or official school record in English
7. ____ Letter of Residence (Connecticut Address and Home Country Address MUST BE NOTARIZED)
8. ____ Affidavit of financial responsibility: (MUST BE NOTARIZED) Letter from a friend, relative or associate stating
that they are going to provide for you financially.
9. _____ FINANCIAL PROOF (notarized bank statement & converted in U.S. currency)
10. ____ COPY OF CURRENT PASSPORT/I-94 CARD (only for student who have a passport.
11. ____ Complete the I-901 form for SEVIS application and send $200.00 fee to USCIS ( New/Initial Students ONLY)
TRANSFERRING IN FROM ANOTHER U.S. COLLEGE
____
Submit all international student requirements stated above
____
Copy of student’s SEVIS I-20 from previous school.
____
Submit official transcript(s) from previous college(s) with final grades and course catalogues.
____
Transfer SEVIS Release form to transfer from previous school to HCC: (see page 9).
Prior college must state you do not owe any money and you are a full time student in good standing and
maintaining your visa status. This form must be signed by foreign advisor from previous college (see page 9).
____
Foreign College Credits must be evaluated by a licensed agency such as WES and ECE.
____
Out of Status students must be reinstated from the previous college attended before applying for admissions.
Required Forms for Change of Status
____
Submit all international student requirements stated above (see page 1)
____
Complete the Change of Status packet including the I -539 form.
14
900 Lafayette Boulevard, Bridgeport, CT 06604-4704 (203) 332-5100 Fax: (203) 332-5294
900 Lafayette Boulevard ·Bridgeport, CT 06604-4704
www.housatonic.edu
A Member of the Connecticut Community College System
Application for Admission
This application is to be used by a NEW - DEGREE AND CERTIFICATE or NON-DEGREE
applicant who intends to enroll as a full-time or part-time student.
NEW DEGREE AND CERTIFICATE STUDENT
A new Degree and/or Certificate applicant is an individual who has never attended Housatonic Community College and
wishes to enroll in a degree or certificate program, a NEW-DEGREE AND CERTIFICATE applicant must:
• Complete all pages of the application and return it, along with a non-refundable $20 application fee, to the Housatonic
•
•
•
•
•
Community College Admissions Office (Please make check or money order payable to Housatonic Community
College). NOTE: All First-time applicants for any semester must pay a non-refundable $20 application fee.
Please check your anticipated Status
Part-time (11 credits or fewer credits
Full-time (12 or more credits)
Students who have attended other Connecticut Community Colleges do not have to pay the $20 application fee.
Have your high school transcript or diploma or GED results and transcripts from any other college(s) attended sent to
the Admissions Office. THIS IS THE APPLICANT'S RESPONSIBILITY.
Proof of immunization: Beginning August 1, 2010, all incoming freshman will be required to show two (2) proofs of
immunity to measles, mumps, rubella and varicella (MMRV). For more information refer to the College catalog and
Student Handbook, applicant checklist, or call Health Records at (203) 332-5062.
Provide proof of proficiency in English and Math, or take the college placement test.
Note: Satisfactory completion of college level English and Mathematics course work may result in waiving the need for an
applicant to take the Accuplacer Placement Test normally administered to incoming students. Please check with the
Admissions Office regarding these test waiver qualifications.
NON-DEGREE STUDENT
A Non-Degree applicant is an individual who does not intend to enroll in a degree or certificate program at this time. Please
Note: All Non-Degree Students are part-time and limited to no more than 11 credit hours per semester (Non-Degree
students are NOT eligible for federally funded financial aid, they need to enter in a Degree or Certificate Program.) NONDEGREE STUDENTS: Please see criteria below:
• Complete all pages of the application, indicating a curriculum code choice of EZ99 (Non-Degree Student), and return it
with a non-refundable $20 application fee. (A student who is readmitting as a Non-Degree Student needs to fill out a
Pink Re-Admit application).
• ESL students not enrolled in a degree or certificate program and only taking an ESL course, indicate a curriculum code
• of EZ99 (Non-Degree Student).
• Non-Degree Students cannot take English or Math courses without completion of the placement tests, proof of college
level proficiency or other test waivers (ACT, SAT, AP).
SPECIAL NOTE
• Social Security Number: Disclosure of the number is requested.
• Home-schooled students must contact the Admissions Office prior to being enrolled.
• All Students born before 1/1/1957 taking online courses only do not have to provide proof of MMRV.
HCC-6 REV. 12/2011
Admissions Office
Phone (203) 332-5100
For Office use only
(203) Date__________________________
BANNER @
Received _____________ Entered _____________________
Entered by _________________________________________
Admit Type _____________ Student Type ________________
Ability to Benefit met _____ Yes _____ No
Application Fee paid _____ Yes _____ No
Cash ____ Check #____________ Waived ______________
Credit Card ______________ Deferred __________________
+&&$GPLVVLRQV2IILFH
/DID\HWWH%OYG%ULGJHSRUW&7
900
Lafayette Blvd., Bridgeport, CT 06604-4704
APPLICATION FOR ADMISSION
Applicant’s Legal Name
(Last)
(First)
Former Last Name(s)
-
(Middle)
-
/
(Social Security Number)
/
(Date of Birth)
(Gender: M/F)
(Social Security Number is requested for purposes of financial aid, Federal income tax benefits, the provision of some College services, accuracy of student
records and other business purposes.)
Mailing Address
Street
City
State
Zip
Street
City
State
Zip
Permanent Address
Telephone
Home
Work
Cell
E-mail
(used for correspondence from the College)
Have you ever attended this college?  Yes  No
If yes, when? ________________________________________________
Have you previously attended a CT Community College?  Yes  No If yes, where?________________________________
For which semester are you applying?  Fall (Sept-Dec)  Spring (Jan-May)  Winter (Dec-Jan)  Summer (Jun-Jul) Year____
CITIZENSHIP
Are you a United States citizen?  Yes  No
If no, are you a Permanent Resident? (Green Card holder)  Yes  No
ETHNICITY/ RACE
Please provide the following ethnicity and race data. This information is requested on a Voluntary basis by the U.S. Department of Education,
National Center for Education Statistics. Your answer will not affect admission to or registration in the college.
Do you consider yourself to be Hispanic/Latino?
What is your race?
Select one or more:
 Yes  No
 White(10)
 Black or African American(20)
 Native Hawaiian or Other Pacific Islander(80)
FAMILY EDUCATIONAL BACKGROUND
 Asian(45)
 Other(90)
Do either of your parents hold a Bachelor’s Degree (4-year College Degree) or higher?
 American Indian or Alaskan Native(50)
 Yes  No
MILITARY STATUS
Are you currently on active duty with the U.S. armed forces?
 Yes  No (ACTD)
Are you currently a member of the National Guard or Reserve?
 Yes  No (NGRE)
Have you ever served in the U.S. armed forces?
 Yes  No (VET1)
Are you a dependent of a member of the U.S. armed forces?
 Yes  No (VETD)
If you answered “Yes” to any of these questions you may be entitled to benefits and you should meet with the College’s Veterans Certifying
Official (VCO).
IN-STATE TUITION
1. I am eligible for in-state tuition because I have continuously resided in Connecticut for at least one year and Connecticut is my permanent
home. _____ Yes _____ No
2. Even though I answered “No” to the question above, I claim and can demonstrate through documentation that I am eligible for in-state tuition.
_____ Yes _____ No
Out-of-state students may be eligible for a reduced tuition rate through the NEBHE program. For details, see the college catalog or website.
3. ___ Check here if applying under the New England Regional Student program (NEBHE).
If you answered “Yes” to question #2 or checked question #3, you must submit a “Declaration of Eligibility for In-State or NEBHE
Tuition” for review and determination of eligibility.
DEGREE STATUS
In which Degree/Certificate program are you planning to enroll?_________________________________________________________________
Please write major name and code above.
Use list of majors/codes on back of application.
HIGHEST DEGREE LEVEL (check one only)




No High School Diploma or GED(01)
Undergraduate Certificate (05)
Master’s Degree (09)
First Professional Degree (JD, MD, DDS, LLB) (12)




High School Diploma or GED(02)  Some College (06)
Associate’s Degree (07)  Bachelor’s Degree (08)
Other Advanced Degree (10)  Doctoral Degree (11)
Sixth-Year Certificate (13)
EDUCATIONAL GOALS





Certificate (credit) (CT)  Transfer without an Associate’s Degree (DN)  Improve English Skills/Proficiency (ES)
Associate’s Degree (DG)  Job Preparation/Retraining Course (JB)
Developmental (College Preparation) Education (DV)
Fulfill other college’s requirement (AC)  Job Promotion (JP)  Unsure at this time (UN)
Transfer with an Associate’s Degree (DT) Personal Development Course(s) (PD)  Other Goal (NL) _____
ACADEMIC BACKGROUND
Do you have a High School Diploma?  Yes  No  Pending Graduation Year _____________________________________
Name of High School__________________________________Town_____________________________State_____Country _______________
Do you have a General Equivalency Diploma (GED)?  Yes  No Year______ GED Number________ Town/State __________________
Do you have an Adult High School Diploma? Yes  No Graduation Year___________Town/State________________________________
Do you have a Home School Diploma?  Yes No Graduation Year___________Town/State_____________________________________
Have you participated in the High School Partnership Program through the CT Community Colleges?  Yes  No
Have you participated in the College Career Pathways/Tech Prep Program through the CT Community Colleges?  Yes  No
PREVIOUS COLLEGE BACKGROUND
College/University Name State Dates of Attendence Graduation Date Degree Awarded
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
INTERNATIONAL STUDENT INFORMATION
Are you an International Student who needs an I-20 form for an F1 Visa?  Yes  No
Other Visa Holder (indicate type)______________________________ Visa Admission Number ______________________________________
Visa Start Date_______________________________________ Visa End Date _____________________________________________
International Address _________________________________________________________________________________________________
EMPLOYMENT INFORMATION
 Employed Full Time
 Employed Part-time
 Unemployed
Name of Employer___________________________________Address of Employer_________________________________________________
Title/Position_______________________________________ Does your Employer have a Tuition Reimbursement Program?  Yes  No
E-MAIL COMMUNICATIONS
I request the College forward to me at the e-mail address I have provided all correspondence, including personally identifiable information
pertaining to me from College records that are protected by FERPA.
Signature: _________________________________________________________ Date: _____________________________________
CONSENT FOR THE DISCLOSURE OF EDUCATION RECORDS
I understand that to maintain accurate student records, including the records pertaining to my attendance at the College, and for other
necessary business purposes, the College may need to release or provide access to personally identifiable information in its records pertaining
to me to another College in the Community College System or to the System’s administrative office. Accordingly, I hereby authorize the College
to release or allow access to such information to those indicated for the purposes described.
Signature: _________________________________________________________ Date: _____________________________________
I certify with my signature below that I am the applicant and that the information I have provided above is accurate.
If admitted, I pledge to comply in good faith with all the rules and regulations of the College. I realize that any
misleading information provided by me on this application may be cause for dismissal. I understand that information
collected in this application is for reporting purposes only and will not be used in the selection process for admission.
Student Signature_________________________________________________________________________Date_______________________
Parent/Guardian Signature (if under 18)_______________________________________________________Date_______________________
Programs Designated With Asterisks (**) Have Special Admission Requirements
HCC DEGREE PROGRAMS
Accounting
Accounting- Small Business Option.
Aviation Maintenance
Banking
Business Administration Programs
General
Customer Service/Marketing Option
Finance Option
Global Business Option
Human Resource Management Option
Management Option
Small Business Management Option
UConn-Stamford/Waterbury Transfer
Program
Business Office Technology Programs
Executive Assistant Option
College Of Technology Pathway Programs
Engineering Science Option
Technological Studies Option
Technology Studies: Electrical Option
Technology Studies: Industrial Tech.Option
Computer Information Systems
Criminal Justice
Early Childhood Inclusive Education
Fine Arts: Art
General Studies
Graphic Design
Multimedia Option
Human Services
Liberal Arts & Sciences
Humanities/Behavioral & Social Sciences
Journalism/Communication Concentration
Mathematics/Science Concentration
Pre-Engineering Science Concentration
Pre-Environmental Science Concentration
Non-Degree/Non-Matriculated
Medical Assisting
Nursing**
Occupational Therapy Assistant**
Pathway to Teaching Careers
Theater Arts
Degree
Code
AS
AS
AS
AS
Primar
y Code
EA03
EA61
EA30
EF08
Dept.
Code
0028
0028
0130
0028
AS
AS
AS
AS
AS
AS
AS
AS
EA67
EB55
EA56
EA65
EB56
EA60
EA89
EA67
0028
0028
0028
0028
0028
0028
0028
0028
AS
EB18
0028
AS
AS
AS
AS
AS
AS
AS
AA
AS
AS
AS
AS
EB16
EF11
EF06
EF19
EB60
EB13
EA99
EB20
EB30
EB33
EB70
EB35
0130
0130
0130
0130
0028
0019
0019
0108
0096
0108
0108
0019
AA
AA
AA
AA
AA
0000
AS
AS
AS
EB45
EB46
EB42
EB47
EB48
EZ99
EA10
EB30
EA77
0019
0108
0130
0130
0130
0000
0130
0130
0130
AA
AA
EC35
EB61
0019
0108
** Special Admissions Requirements
Please let us know the source(s) of information that led to
your decision to attend HCC by checking the boxes below:
□ HCC Admissions Representative
□ High School Guidance Counselor
□ Family (parents, siblings, cousins, etc.)
□ Social Media, specify____________________________
□ Connecticut Post
□ Town/Neighborhood Newspaper
□ Spanish-Language Newspaper
□ English Radio, provide station_____________________
□ Spanish-Language Radio
□ Bus Ads
□ Billboard
□ Other, please specify ____________________________
HCC CERTIFICATE PROGRAMS
Business Certificates
Admin. Support Assistant
Retail Banking
Small Business Management/
Entrepreneurship
Computer Information Certificates
PC Applications
Personal Computer Repair Technology
Web Design Technology
Criminal Justice Certificates
Corrections
Criminal Investigation
Police Management & Administration
Early Childhood Education Certificates
Early Childhood Education
Early Childhood Education Administrator
Infant/Toddler
Child Development Associate
Preparation
ESL Certificates
Advance English Proficiency
Graphics Certificates
Graphic Design
Web Design Graphic Foundation
Health Careers Certificates
Health Careers Pathways
Human Services Certificates
Behavioral Healthcare - Track I
Behavioral Healthcare - Track II
Child & Youth Mental Health
Disabilities Specialist
Manufacturing Certificate
Advanced MFG: Machine Technology
Math/Science Certificates
Electrical
Theater Arts
Performance Track
Degree
Code
Primary
Code
Dept.
Code
CERT
CERT
EJ09
EK04
0028
0028
CERT
EK05
0028
CERT
CERT
CERT
EJ01
EJ02
EK07
0028
0028
0028
CERT
CERT
CERT
EJ62
EJ61
EJ06
0019
0019
0019
CERT
CERT
CERT
0000
EJ89
EJ79
EJ07
EJ73
0019
0019
0019
0019
CERT
EJ03
0069
CERT
CERT
EJ91
EK06
0108
0108
CERT
EK55
0130
CERT
CERT
CERT
CERT
EJ67
EJ68
EJ71
EJ72
0019
0019
0019
0019
CERT
EK60
0130
CERT
EN12
0130
CERT
EJ08
0108
APPLICANT CHECKLIST
HAVE YOU…
___ Turned in the non-refundable $20.00 check or money order
application fee?
___ Picked a degree or certificate program? (non-degree students DO
NOT qualify for financial aid)
___ Provided two (2) proofs of immunity to
measles/mumps/rubella/varicella (MMRV)?
Exemptions
*born before January 1, 1957
*Taking online classes only
*Part-time and not matriculated
For more information call Health Records at (203) 332-5062
___ Provided copy of High School Diploma or Transcript and/or
GED?
___ Contacted Financial Aid Office for a Financial Aid Application?
st
Call 332-5047 (at least 6 to 8 weeks prior to 1 day of
classes) or via the FAFSA web site at www.fafsa.gov
___ Provided proof of citizenship/residency/passport if applicable?
Visa applicants are required to pay out of state fees.
___ Visited Admissions Office to request evaluation for college
credit?
If you are interested in transfer credit, please have all official college
transcripts sent to the Admissions Office. Transcripts must be received
before being advised. All foreign College transcripts MUST be evaluated
first by a Foreign Credentials Agency and sent to the Admissions Office.
Additional information is available in the Admissions Office