FACULTY AND PROGRAM LEADER ORIENTATION PACKAGE (Revised March 2015) TABLE OF CONTENTS WELCOME .................................................................................................3 FACULTY SERVICES STAFF .............................................................................4 COMPENSATION DETAILS ..............................................................................5 TRAVEL INFORMATION VISAS AND WORK PERMITS ...........................................................................5 PASSPORT INFORMATION ..................................................................................... 5 TRANSPORTATION-FLIGHT ARRANGEMENTS .............................................................. 6 U.S. CUSTOMS .................................................................................................. 7 BAGGAGE AND SHIPMENT ..................................................................................... 7 INOCULATION AND MEDICAL CONCERNS .................................................................. 8 MONEY/CURRENCY ......................................................................................8 HOUSING ......................................................................................................... 9 COMPANIONS .................................................................................................... 9 ACADEMIC INFORMATION GENERAL INFORMATION................................................................................10 COURSE DESCRIPTIONS AND COURSE TEXTBOOK ADOPTION ......................................... 10 PLANNING YOUR COURSES ................................................................................... 11 SOCIAL/CULTURAL EVENTS ............................................................................12 SYLLABI........................................................................................................... 12 GRADES .......................................................................................................... 13 ATTENDANCE .................................................................................................... 14 ACADEMIC CALENDAR ......................................................................................... 14 COURSE EVALUATION .......................................................................................... 14 CRIME & SAFETY SAFETY TIPS .............................................................................................15 APPENDIX I: INTERNATIONAL TEACHER IDENTIFICATION CARD ...............................17 Congratulations on being selected to teach on an FSU International Program! 2 We are delighted to have you as an integral part of our team. Now that you have been accepted, we offer you this packet of information to assist you with your next steps. These are some preliminary issues you should consider as you prepare for your overseas teaching assignment. It is of extreme importance that each Program Leader and faculty member is knowledgeable with the details of his/her program’s safety and emergency procedures. While the Program Leader (for programs not housed wholly in a city with a year-round Study Center) is responsible for the development and execution of his/her program’s specific plan, it is essential that all faculty members on the program are knowledgeable and able to assist with its implementation. We strongly encourage you to read the “Program Leader Operations Guide” to better prepare yourself in the event of an emergency. All Non-Study Center Program Leaders and faculty, and any faculty who are responsible for students outside of their Study Center, are required to attend Faculty Orientation in Tallahassee prior to leaving Tallahassee. The International Programs Program Management Staff will notify you of the orientation dates and times. Program Leaders and faculty at Study Centers are also responsible for understanding and supporting the safety and emergency procedures at their respective Study Center locations. All faculty are responsible for their students in class and during academic field trips. Safety plans, emergency procedures, and emergency telephone numbers will be provided at the onsite faculty orientation. All Study Center and Program Leaders and faculty are required to attend the onsite Faculty Orientation. The International Programs Management Staff will contact the faculty on the date and time of the orientation (which is usually the day before the students arrive for the program.) We ask that you read this packet carefully, comply with the established deadlines, and read the information and documents thoroughly. If you do not have all the information required, or if you have any questions, please contact our office. Our goal is to assist you in the planning of a successful study abroad experience. 3 Program Management Staff Listing Dr. Ceil Bare Director, Program Management cbare@fsu.edu 850-644-1283 Ms. Jennifer Fisher Academic Program Coordinator jafisher@fsu.edu 850-644-7622 Ms. Mery-et Lescher Academic Program Coordinator mlescher@fsu.edu 850-645-1061 Ms. Gisela Fisher Internship Coordinator gfisher@fsu.edu 850-644-7217 Our office is located at: International Programs Florida State University A5500 University Center 282 Champions Way PO Box 3062420 Tallahassee, FL 32306-2420 Tel: (850) 644-3272 or Toll free: (800) 374-8581 Fax: (850) 644-7242 4 COMPENSATION DETAILS_________________________________________ Fall/Spring Florence, Italy; London, England; Panama City, Panama; Valencia, Spain. International Programs (IP) provides the following: Spain/London/Florence: (as outlined in your assignment letter) Coach class round-trip airfare Per-diem of $3000 Portion of salary reimbursement to Florida State University home department Medical Emergency Evacuation Insurance Shipping allowance (varies by program) Panama: (as outlined in your assignment letter) Coach class round-trip airfare Housing in FSU arranged facilities Portion of salary reimbursement to Florida State University home department Medical Emergency Evacuation Insurance Shipping allowance (varies by program) Summer - All locations International Programs provides the following: Coach class round-trip airfare (as outlined in your assignment letter) Stipend per course – based on minimum enrollment* Housing in FSU arranged and designated facilities for faculty and one companion. Health and Emergency Evacuation Insurance Shipping allowance (varies by program) Program Leader Stipend as approved by International Programs *Minimum student enrollments may apply and may vary per location. For more information or questions regarding financial information, and program leader stipends please contact Ceil Bare at: cbare@fsu.edu or Chris Carroll at ccarroll@fsu.edu TRAVEL INFORMATION__________________________________________ Visas and Work Permits For Visa, Work Permit and Dependent Entry Clearance Information: Contact Tina Brooks at cbrooks2@fsu.edu for information for your particular program’s location. Passport Information If you have not already done so, please apply for your U.S. passport now! It will take at least 4–6 weeks to process, longer if you must send away for your birth certificate. 5 Birth Certificate. You will need an official birth certificate from the Bureau of Vital Statistics in the state in which you were born. (It must have the Bureau’s seal embossed on the paper). The main post office can give you the address of the office in your native state and the cost of the certificate, or you can find this information via the Internet at: vitalrec.com/index.html. Check with your local county board of health for information obtaining birth certificates. Passport Application. Florida State University International Programs has been designated a Passport Acceptance Facility by the U.S. Department of State. Students, faculty, staff, and members of the community can apply for a U.S. passport and/or passport card directly through our office, thus bypassing a special trip to the courthouse or post office. As a Passport Acceptance Facility, we are authorized to receive your completed application for a U.S. passport and submit the application and all necessary documentation to Passport Services on your behalf. Passport Services will then determine eligibility for a U.S. Passport. It is important to note that only Passport Services can make the final decision to issue a passport to an individual. As part of our services, our Passport Acceptance Facility can provide you with the necessary forms required to apply for a U.S. passport, as well as other passportrelated forms. In addition, we are authorized to accept applications for the new U.S. passport card. We also offer an on-site passport photo service. Passport Photographs. Two official passport-size pictures (2 in. x 2 in.) are needed for your passport application. You may purchase passport photos at the International Programs Passport Office, most copy centers, drugstores, or travel agencies. Also, your travel agent may provide this service free of charge. Passport Copies. Make three photocopies of the pages in your passport that contain the issue date, your signature, and your photograph. Leave one copy at home with a relative or friend, take one for the Study Center (if you are teaching at a Study Center location) and carry one separate from your passport in case it is lost or stolen. Please email a digital copy of that page to Jennifer Fisher in the Tallahassee office at jafisher@fsu.edu prior to departure. IMPORTANT: The passport must not expire within 6 months of your return (9 months in Italy) to the United States. If it does, you must apply for renewal of your passport before your departure. Transportation-Flight Arrangements Airfare is provided for all Program Leaders and faculty members. Faculty are responsible for making transportation arrangements to and from the international location for themselves and their families. While we advise you to book your flights; please, DO NOT purchase a ticket until IP has confirmed your assignment. You are welcome to make a flight reservation to arrive/depart on different 6 dates to/from different locations. However, International Programs will only reimburse up to the price of a ticket as discussed above. Once you purchase your ticket, please fax or email a copy of your itinerary showing the price, ticket number and form of payment to Patti Wilmer at: 850-645-0919 or pwilmer@fsu.edu. You may choose to book your ticket using your own travel agency or through an on-line website; however, International Programs is not authorized to recommend a travel agency. NOTE: International Programs cannot reimburse you for a ticket purchased with frequent flyer miles. We will only be able to reimburse the taxes associated with that purchase. You should arrive at the international airport check-in desk at least 3 hours before your scheduled departure. Make sure that your baggage is checked through to your final destination. Please, do not book your airline ticket until you receive approval from International Programs Program Management. Your approval will include your approved arrival and departure dates. U.S. Customs You should have no difficulty with U.S. Customs or Customs in your host country, although there are limits on the amount of tobacco you may take into a country. When you return to the U.S., you will undergo careful inspection at U.S. Customs. Please be sure to check the below U.S. Customs website concerning duty regulations. https://help.cbp.gov/app/home Baggage and Shipment Since the charges for excess baggage can be very high, be certain to obtain precise information on baggage weight and size regulations. If you plan to fly from one European country to another, be advised that baggage regulations may be very different than they were on your flight from the U.S. to your initial overseas location. Please check with your airline for up-to-date policies and regulations since they are constantly changing. Generally, luggage is limited to one checked bag and one carry-on for international flights. If you plan to ship materials to your overseas location before you leave the U.S., we advise that you ship by Air Parcel to allow plenty of time for their arrival (8 to 12 weeks). But keep in mind this can be an expensive option. You may wish to ship by Surface Post, but using this method may require several months for your material to arrive. Check all shipment times with your local Post Office. Your compensation includes 7 a shipping allowance that may be used to cover excess baggage fees, baggage weight penalties, and/or shipping costs. Approved shipping allowances vary by program. You will receive the specifics of your approved shipping allowance in your invitation letter. For reimbursement, you will need to email the original receipt to Patti Wilmer at: International Programs Florida State University A5500 University Center 282 Champions Way PO Bos 3062420 Tallahassee, FL 32306-2420 All normal living supplies are readily available at your overseas locale. Remember that American electrical appliances are rarely usable except with the purchase of a converter and often a transformer. Florida State University is not responsible for the loss of or damage to your personal items. It is advisable that you obtain a short-term personal property insurance policy if you are not already covered by your present policies. INSURANCE INFORMATION International Programs will provide full medical/evaluation coverage for all approved faculty from the United States through our Cultural Insurance Services International (CISI). Students participating in all of our study abroad programs are also covered by this same insurance policy. For more information regarding your coverage please see CISI’s insurance policy posted on the International Program’s website at: http://international.fsu.edu/Usercontrols/docs/CISIInsurancePolicy.pdf Inoculation and Medical Concerns It is very important that you are aware of the specific requirements and health matters in your program location. Information is available through the Centers for Disease Control and Prevention’s website: http://wwwnc.cdc.gov/travel/default.aspx Tetanus booster. A tetanus booster shot is suggested if you have not had one within the past 10 years. Regular Medication. Bring a good supply with you, as well as any doctors’ prescriptions. (Make sure the prescriptions are legible and include the chemical formula.) Glasses or contact lenses. Take an extra pair or the prescription. Medical and dental care. Get routine medical and dental care before you leave. 8 Money/Currency Your stipend will be deposited directly to your home checking account in the United States during the pay periods of your assignment overseas. If you have an American ATM card from the PLUS group, you can use that card to obtain immediate cash from your American bank account at most bank cash machines. It is advisable to contact your financial institution to advise them that you will be using your ATM or credit card(s) overseas. Some banks are now charging an international currency conversion fee; please contact your bank to see if this applies to you. The exchange rate is set daily, and you can draw the same limit as imposed on stateside transactions. By using this option, you will avoid costly bank/exchange office conversion fees and only pay the charge assessed for making an ATM cash withdrawal. Make sure your ATM card “works” before you leave the country. Put money in your checking account, and use your ATM card to access the funds. If you experience problems, contact your bank. Please note that most ATM machines overseas do not have alphabetical letters on the keyboard, so make sure you have a numerical PIN number. Your ATM card will not access funds from a savings account while overseas. If you will be using Traveler’s Checks, take enough to be used in case of an emergency (i.e. loss of ATM card, power outage). If you have an American Express card you can immediately cash personal checks drawn on your own account in the U.S. at any American Express office. However, we discourage the use of travelers’ checks since many locations no longer accept them. Housing On summer programs, housing is provided for the faculty member that will also accommodate one traveling companion in the same room, at no additional charge. Fall and Spring faculty are responsible for securing their own housing. Faculty teaching at a Study Center are required to arrive one day prior to the program start date. If you intend to arrive at your overseas location earlier than that date or stay later than the end of the program, you must make special arrangements for the additional housing dates. You will be responsible for expenses incurred on the extra days. For additional dates in London housing, payment is to be made directly to Acorn Educational Services. London faculty will receive a separate housing memo during the spring term, prior to your summer assignment. If you are planning on bringing relatives and/or friends, please keep in mind there may be costs involved, and our overseas locations have limited space and may not be able to accommodate all of your needs. Please contact Gisela Fisher at gfisher@fsu.edu for further information. Companions 9 In the summer, housing is provided for you and one companion. All faculty will be asked to provide information on each of their companions that will be accompanying the program. It is vital for the safety and security of each of your companions that you inform IP of their participation. All Teaching Faculty and Program Leaders at a Study Center are strongly encouraged to purchase medical and emergency evacuation insurance for companions. At the end of the program, you will be invoiced for any costs incurred by International Programs for your companions. For insurance rates, please contact Gisela Fisher at gfisher@fsu.edu. Insurance will be provided for Program Leaders, Faculty, and their companions when not based at a Study Center. International Driving Permit In the event that you plan to drive a car while you are abroad, you may want to look into obtaining an International Driving Permit. For more information, visit: http://www.aaa.com/vacation/idpf.html ACADEMIC INFORMATION________________________________________ General Information The office of International Programs seeks to build an integrated curriculum that will provide opportunities for students to make normal progress toward their degree. Summer teaching assignments vary. If your teaching schedule permits, as a qualified faculty member you may be asked to accept Directed Individual Study (DIS) work with students majoring in your discipline. In addition, you may be asked to be a Professor of Record for a student participating in our Internship Program. Students give the best course evaluations to those faculty who can and do involve their classes in the cultural settings. Maintaining acceptable high standards on overseas programs requires constant effort and considerable skill. It is also very important that you consider ways in which your classes can blend effectively with the mission and purpose of your overseas study program or Study Center. Course Descriptions and Course Textbook Adoption When you applied, you were asked to submit a course description and textbook list. It is imperative that we have this information for your students so that they may acquire any needed texts prior to their departure. The course description you submitted will be displayed on the International Programs website, as a link from the list of courses to be offered each term. Based on these descriptions, students will be able to determine the courses they may want to take, or even on which program they will want to participate. 10 Thus, it is important to make the descriptions exciting by showing how your course will utilize the environment in which it will be taught. Non-FSU students may also request a sample syllabus in order to receive pre-approval from their home institutions for the courses they wish to take while on the program. Prior to registration, you will be asked to review your on-line course description to determine if there is a need for a change. You will also be asked for any changes in your textbook requirements. Textbooks will not be ordered through any local source. Students will purchase their books from any source they choose, including on-line. Course Textbook Adoption As per the Higher Education Opportunity Act (2008), Section 112, information regarding required course textbooks and course materials for courses taught at our Study Abroad locations will be posted on the FSU Textbook Compliance Portal by the IP Textbook Compliance Coordinator, Mery-et Lescher. Faculty will receive a course textbook form for submitting this information to Mery-et for each of their classes. If you have any questions regarding Textbook Compliance, please contact Mery-et Lescher at: mlescher@fsu.edu Planning Your Courses International Programs is a strong proponent of the concept “The World is Your Campus.” Teaching a course in the same manner as it is taught in Tallahassee is contrary to the spirit of international study. Class sessions need not meet solely in the classroom. Courses taught internationally should be enhanced by their location, and we recommend you take full advantage of all the resources available to you. The finest museums, theatres, and historical sites are at your disposal, so you will be expected to get your students out into the streets to explore all your chosen country has to offer. Course related field trips incorporating academic lectures are classified as classroom contact time for the duration of the lecture or instruction. Course related field trips without formal accompanying instruction count as half class time for the period allotted by the instructor. You are encouraged to utilize travel time to and from the location for instruction. Maintaining high academic standards requires constant effort and considerable skill. Obviously, many distractions from academic work are a part of the students' lives in a foreign country. The students are in a new and alluring environment. They invariably want to travel and explore. Travel and exposure to the culture are important to the students' education, but this must not be at the expense of academic standards. So you, as faculty, must exercise all of your diplomatic and teaching skills to make your courses so engaging that the students will want to attend every session! This is not an easy task, but involved faculty will find a way. It must be stressed that student access to library facilities, computers and reliable internet access will be much more limited than on the home campus. You must take 11 this into account when assigning research papers. Focusing outside class assignments on direct contact with the culture is a wise alternative. It would be a mistake to assign papers requiring the kind of library research expected on Florida State’s campus. Whenever possible, assignments should be creative mixtures of traditional materials and the international environment. Contact time required per credit hour is 750 minutes A 3 credit hour class will need a total of 37.5 hours of teaching contact time. Academic Field trips without teaching/lecturing count as ½ time. For example if your field trip lasts 4 hours, only 2 hours will count as teaching contact. Social/Cultural Events The university provides social and cultural events that are open to all participants without additional charge, or at a reduced fee. These events may include concerts, lectures, special visits, or day-trips to surrounding localities. Program Leaders must attend all program related social cultural events and we encourage faculty to participate in program-planned social/cultural events. Families of faculty are invited to participate in such trips on a prorated cost and space-available basis. Past faculty agree that participating in such trips was one of the most rewarding aspects of the program because it allowed them to get to know students on a personal basis and to share with them a common learning experience. Faculty members who have ideas for specific lecture(s) or field trips should contact the appropriate Study Center Director well in advance. Syllabi An electronic copy of your final syllabi must be provided to your Resident Study Center Director or Program Coordinator during the first week of classes. Each syllabus must be as comprehensive as possible; clearly setting forth fully the requirements for the course. It is important that you make the standards for the course absolutely clear in this syllabus at the outset. Objections inevitably arise when new requirements are added in mid-course. Grade appeals are often determined by the clarity of syllabi. Please see below for the University’s guidelines for creating your syllabus. University and Faculty Senate policy requires that a course syllabus be distributed at the beginning of the semester that includes: written course objectives; an evaluation (grading) statement that indicates what procedures will be used to evaluate students and should make it possible to discern the approximate weight of each grade component; an Americans with Disabilities Act (ADA) statement (sample statement at http://facsenate.fsu.edu/Curriculum-Forms/Policies or at http://www.disabilitycenter.fsu.edu/faculty.html); 12 a statement regarding academic integrity (see the Academic Honor Policy in Appendix A of the Faculty Handbook or at http://facsenate.fsu.edu/CurriculumForms/Policies); and the attendance policy (if applicable). It is recommended that instructors include a statement of their policy and/or expectations regarding classroom conduct and missed work. It is also recommended that instructors include a statement regarding the availability of tutoring on campus. (See sample at http://facsenate.fsu.edu/Curriculum-Forms/Policies). Once the course has begun, no changes should be made to the syllabus that will substantially affect the implementation of the instructor’s grading [evaluation] statement. Below is a link to helpful information to use when creating your syllabus. http://distance.fsu.edu/instructors/preparing-syllabus-university-approvals There may be other required entries based upon your course’s designation, for example, Liberal Studies. Please double check with your home department as to any requirements for your specific course. For further information concerning syllabi requirements, please contact Chris Carroll at ccarroll@fsu.edu As a practical matter, when thinking through the assignments, keep in mind the nature of the overseas study environment. Spread your assigned coursework throughout the term. Assess your students’ progress periodically. Do not pile on the work at the end of the semester, and discourage students from postponing assignments. Also, keep in mind that you may have expenses associated with your course that you may not have at home. For example, museum entrances, tickets, transportation costs. If you have expenses associated with your class that are not included in your program fee, you must indicate the additional expenses as specifically as possible on your syllabus. Grades All instructors are required to submit their grades online. Grades are submitted through the FSU Blackboard system, even if you are not using Blackboard for your class. There will be roughly a two-week period for grade submission at the end of the term. Your rosters will not appear on the website until this time. Those dates will be announced at a later time. Important: Please take the time to make sure you are able to login to Blackboard at least one month before the end of the term. For complete instructions on how to submit your grades please click on the grades link that appears on our website at http://registrar.fsu.edu/services/staff/grades_faq.htm For grade changes, Incompletes, No Grades or any necessary changes to grades even after the term’s grades have posted, please go to: 13 http://sc.my.fsu.edu/Faculty/How-To/Request-a-Grade-Change Attendance Rosters are available through Blackboard, or from Study Center staff. You are required to take attendance the first week of classes and report any discrepancies to the Study Center Director or your Program Coordinator, and again after drop/add. If you fail to do this, your department will be fined for EACH discrepancy on the roster. In addition, we encourage you to take regular class attendance. Develop an attendance policy and include it in your syllabus. Academic Calendar Your overseas study location academic calendar may not correspond with the Tallahassee campus calendar. At the Study Centers, we strive to allow for students’ personal travel. Once the Resident Directors have finalized the proposed schedule of events for the semester, a copy of the calendar will be sent to all faculty. NOTE: Mid-term breaks do not apply to six-week or shorter summer programs. Course Evaluation Each student will be asked to complete evaluations of the program and the courses that they completed. Program evaluations will be provided to the students by the International Programs staff, while course evaluations (SPOT) will be provided to the students electronically by the Office of Assessment Services at FSU. These evaluations will help us prepare a report on the program and hear the opinion of the students in regards to their overall experience. Study Center Academic Facilities (i.e., AV equipment, library, lab) For information on available academic facilities in your location please Gisela Fisher at gfisher@fsu.edu or your Program Coordinator. CRIME & SAFETY________________________________________________ Safety and security abroad. Crime in general is more common on our home campuses and in the U.S. than it is abroad. This may vary depending on the country, so we ask that you be aware of your surroundings and travel safely. Pickpocketing. As in most large cities throughout the world, pickpocketing is the most common crime and can happen anytime, anywhere. Our office cautions you to always be aware of your surroundings. The U.S. State Department maintains a website of information for Americans living abroad, including current travel advisory warnings, at www.state.gov/ 14 Where to report crimes. Notice is to be given to your Study Center staff, Tallahassee main office and to the police as soon as possible. U.S. Embassy Information. Be sure to make yourself familiar with the closest location of the U.S. Embassy in your country. Current addresses for the U.S. Embassy in specific locations can be found at http://www.usembassy.gov/ For more information go to our website http://international.fsu.edu/ and click on the Safety and Security Tab. Safety Tips/Suggestions You are subject to the laws of your host country. These laws are often much more severe than U.S laws. While traveling, use money belts or neck pouches that are worn under your clothes. Some programs have an office safe in which you can keep valuable papers (passports, travelers checks, airline tickets), but remember the safe is open only during certain hours. Check with your Study Center Staff to see if a safe is available for your use. If not, keep your valuable papers in a secure place. Always carry a photocopy of the picture and facing page of your passport. Keep another copy in your room separate from your passport. Be sure to email a digital copy of your passport to Jennifer Fisher, jafisher@fsu.edu Protection against street robbery includes carrying purses with straps worn across the chest with the clasp turned toward the body and away from the street. Keep your purse between your arm and your body. Cameras should be treated the same way. Billfolds are most secure in a front trouser pocket. When seated in a restaurant or theater, never leave your bag or camera on the floor next to you. It may not be there when you are ready to leave! While traveling in some areas, be aware of beggars who try to distract you with papers, boxes, or excessive body movements. While this is happening, an accomplice, often a child, does the stealing. In general, thieves love confusion and work near places and on the transportation that tourists usually frequent. Shouting and screaming are often good counteractions to street theft. Coats and purses are often stolen in crowded areas. Keep them close to you. Secure your money, passport, and other valuables if you are traveling on an overnight couchette. For Study Center Faculty, in case of a personal emergency, contact your Study Center Director for assistance. In case of a program emergency, follow your Study Center contingency plan and contact your Study Center Director. 15 For Non-Study Center Faculty, in case of a personal emergency contact the International Programs Office for assistance. In case of a program emergency, follow your program plan and contact the International Programs Office. Revised March 2015 K:\IP-Shared\JennFisher\General IP Forms & Info\2016 Forms\Faculty and Program Leader Orientation Package Revised January 2015.do 16 Appendix I: International Teacher Identification Card INTERNATIONAL TEACHER IDENTIFICATION CARD APPLICATION The card is valid from September 1, 2014, through December 31, 2015. (Spring 2016 teachers will receive a card with an expiration date of December 31, 2016.) Please type or print application in clear block letters. Provide personal and beneficiary information, mail photos to our office, and sign the bottom of the form. Photo required. It must be small (passport-size or vending machine size) 2” x 2”. Please include your name printed on the back of the photographs. PROGRAM information Program Location ______________________________ Term Summer 2015 Fall 2015 Spring 2016 Session Code_______________ This code can be found in the brochure or on our website at www.international.fsu.edu PERSONAL INFORMATION Name: _________________________________ Social Security #:________________________ (Last name) (First name) Name of Home School:_______________________________Citizenship___________________ o Please call me at: ______________ or email me at _____________________to pick up the card. OR o Please mail ISIC card to this address: ________________________________________________________________________ BENEFICIARY INFORMATION Your Card carries insurance. Please provide the name and address of a beneficiary. Name:_________________________________ Relationship to applicant:___________________ Address:________________________________________________________________________ City: ___________________ State: ____ Zip:__________ Phone: (______)________________ Signature I hereby certify this information is true. I understand any false statements on my part may result in forfeiture of the benefits associated with this Card. Signature of cardholder: ____________________________________Date:__________________ ****** For Office Use Only ******* I.T.I.C. Number: _____________________________________ Date Issued: ______________ Date called for pick-up:________________________________ Date Mailed: ______________ 17