ESL Program Application 2015-2016
INSTRUCTIONS: Please fill out this application, along with all required supplementary documents, and submit it with a
$50 application fee (money wire or bank check are acceptable) to the Office of International Education (OIE) at Southern
Connecticut State University (SCSU). Scanned documents are preferred (send to: esl@southernCT.edu), although the OIE
will accept hard copies sent via post to:
ESL Coordinator, Office of International Education
Southern Connecticut State University
Engleman Hall B 129
501 Crescent Street
New Haven, CT 06515
Your completed application must include: this form, a copy of your passport, financial document(s), transcripts,
language proficiency scores, additional test scores (if applicable) and proof of health insurance (if applicable). Once
your application is received, you will be notified and may be asked to provide any missing application materials. Your
transcripts and other documents must be evaluated, and you will be contacted once an admission decision has been made.
STUDENT INFORMATION:
Name must appear exactly as it does on your passport.
Name:
Last (Family Name)
First (Given Name)
Middle
Native Language:
Date of Birth:
Gender:
Month
☐ Male
/ Day
/
Year
☐ Female
PROGRAM SELECTION:
Please select your intended program of study and a start date.
Spring Semester (16-week program)
☐ January 15-May 13, 2016
Summer Semester (6-week intensive programs)
☐ May 16-June 24, 2016
☐ June 27-Aug 5, 2016
Estimated Costs of Attendance for the 2015-16 Academic Year
Cost Description
Tuition
Fees
Housing and Meals*
Books
Health Insurance**
Application Fee
Spring Semester (16 weeks)
$9,000
Summer B Semester (6 weeks)
$4,500
Summer Semester (6 weeks)
$4,500
$95
$95
$95
$4,190
$2,550
$2,550
$500
$829
$50
$300
$829
$50
$300
$829
$50
*Cost reflects price of the minimum required meal plan. Selecting an upgraded plan will alter the final estimated
cost.
**Health insurance waivers are obtainable with proper documentation.
How did you learn about our program?
☐ Professional Recruiter
☐ Internet/Website
☐ Friend/Relative
☐ Other:
☐ Newspaper
☐ Guidebook
☐ Phone Book
VISA AND IMMIGRATION INFORMATION:
Country of Birth:
Country of Citizenship:
Country of Legal Permanent Residence:
Visa Type:
☐ J Visa
☐ F Visa
U.S. Residency Status:
☐ Non-U.S. Citizen or Resident
☐ H Visa
☐ Other:
☐ U.S. Citizen/Resident Alien
Do you have a Dual Citizenship? :
☐ Yes
☐ No
If you answered yes, please list additional country of citizenship:
Are you currently living or studying in the U.S.? : ☐ Yes
☐ No
If you answered yes, please include a copy of your visa, I-20, and the contact information of your DSO.
Marital Status:
☐ Single
☐ Married
Will any of your dependents (spouse or children) come to the U.S. with you?
☐ Yes
☐ No
How many?
If yes, please include copies of their passports with your application.
Medical Insurance
The full cost of an SCSU Student Health Insurance Plan will be added to the invoice unless proof of adequate alternative
coverage, as approved by the OIE, is attached.
CONTACT INFORMATION:
Permanent Mailing Address:
Street
City
Country:
Telephone:
State/Province
Postal Code:
Country Code
City Code
Email Address:
Number
The student’s permanent address is required to create the I-20. This address CANNOT be the address of any officer
individual at your university.
Current Mailing Address:
Street
City
Country:
Telephone:
State/Province
Postal Code:
Country Code
City Code
I can be reached at this address until:
Month
Cell Phone:
Number
/ Day
/
Year
Email Address:
-
-
Visa documents should be mailed to:
☐ Current Address
☐ Permanent Address
(Valid from:
☐ International Education Office at home university
to
)
If you would like your I-20 mailed to the International Education Office at your home university, please provide that address
below:
Attn:
Office:
Contact Name
Office Address:
Street
City
Country:
Telephone:
State/Province
Postal Code:
Country Code
City Code
Number
Contact’s Email:
EMERGENCY CONTACT:
Name:
Telephone:
Last (Family Name)
Country Code
First (Given Name)
City Code
Number
Email Address:
Relationship:
Address:
Street
Country:
City
State/Province
Postal Code:
ACADEMIC INFORMATION:
Please list all secondary and post-secondary schools, colleges, or universities you have attended or will attend prior to entering
the university. You must provide a transcript from each post-secondary school, college or university you have
attended, even if you did not complete a term.
Secondary School Information
Name of most recent secondary school attended:
Dates attended from:
to:
Month
/ Day
/
Year
Month
/ Day
/
Year
Graduation Date:
Month
/ Day
/
Year
Month
/ Day
/
Year
List any other secondary schools you have attended. (Attach additional pages as necessary.)
Name of additional secondary school attended:
Dates attended from:
to:
Month
/ Day
/
Year
Month
/ Day
/
Year
Graduation Date:
College and University Information
Name of most recent College/University attended:
Dates attended from:
to:
Graduation Date:
Month
/ Day
/
Year
Month
/ Day
/
Year
Month
/ Day
/
Year
/ Day
/
Year
Degree Earned:
List any other post-secondary schools you have attended. (Attach additional pages as necessary.)
Name of additional College/University attended:
Dates attended from:
to:
Month
/ Day
/
Year
Month
/ Day
/
Year
Graduation Date:
Month
Degree Earned:
Highest degree awarded: ☐High School Diploma
☐Bachelor’s
☐ Master’s
☐ Other:
Gaps in Study
Will it be more than 4 months between the time of filling out this application and the start of your program? ☐ Yes
If yes, will you have attended a school, college, or university in that time?
☐ Yes
Is that school or university indicated on this application or a separate sheet of paper?
☐ Yes ☐ No
☐ No
☐ No
☐ By selecting this box, you testify that you have included information on all of your academic studies and will not pursue
further study prior to joining this university. Failure to provide this information can result in dismissal from the
university.
PRIOR ENGLISH LANGUAGE INSTRUCTION
Have you attended ESL classes? :
☐ Yes ☐ No
If yes, please answer the corresponding questions below.
ESL courses attended at:
Dates attended from:
to:
Month
/ Day
/
Year
Month
/ Day
/
Year
Highest Level Completed:
TEST SCORES
Please indicate all test scores completed. Copies of test results may be used for evaluation, but official results must be
received prior to registration.
English Language Test Scores Valid for two (2) years
☐ TOEFL
☐ IELTS
Date of Exam:
Test Score:
Month
/ Day
/
Year
Month
/ Day
/
Year
Date of Exam:
Test Score:
Academic Test Scores Valid for five (5) years
Undergraduate Student Exams:
☐ SAT
Date of Exam:
☐ ACT
Test Score:
Month
/ Day
/
Year
Month
/ Day
/
Year
Month
/ Day
/
Year
Month
/ Day
/
Year
Date of Exam:
Test Score:
Graduate Student Exams:
☐ GMAT
Date of Exam:
☐ GRE
Test Score:
Date of Exam:
Test Score:
HOUSING
Please select one option from the choices below. If you do not select a housing option, we will not select one for you.
Housing preferences are given based on availability.
☐Apartment Style Residence Hall (North Campus)
☐ Off-Campus Housing*
* Note: You must make your own arrangements if you select “off campus”.
Apartment Style Residence Halls offer double or quad bedrooms with a single bathroom. Students living in apartment style
residence halls have access to full kitchens in their room and air conditioning. Each apartment houses either male or female
residents; floors are co-ed.
ESL students who elect to live on campus will automatically be assigned to North Campus housing, where the International
Student LLC is located. Those interested in exploring other housing options are welcome to visit Residence Life’s page at
http://southernct.edu/student-life/campus-life/residencelife/. SCSU cannot guarantee placement in other residence
halls.
If you selected an on-campus housing option, please indicate how long you would like to remain.
Semesters:
☐1
☐2
STUDENT SERVICES
Meal Plan Membership
Students who choose to live on campus will automatically be enrolled in SCSU’s 25 Meal Block Plus. If you would
like to upgrade to a plan with more meals per week, you may do so. The cost of an upgraded meal plan will be reflected in
your estimated cost of attendance. Specific information about the costs and benefits of each plan can be found online at
http://www.southernct.edu/student-life/campus-life/food-services/meal-plans.html.
DECLARATIONS
Disciplinary Action
Are you currently, or have you ever been, charged with or subject to disciplinary action for scholastic (such as plagiarism or
cheating) or any other type of behavioral misconduct at any educational institution? You do not need to disclose academic
dismissal, suspension or probation for poor grades.
☐ Yes
☐ No
Criminal Conviction
Have you ever been charged with a violation of the law, misdemeanor and/or felony (even if adjudication was withheld) that
resulted in, or, if still pending could result in, probation, community service, restitution, a jail sentence or the revocation or
suspension of your driver’s license (you are not required to include traffic violations that only resulted in a fine)?
☐ Yes
☐ No
If your answer to any of the preceding is YES, details of any offenses should be included on a separate sheet. If your records
have been expunged pursuant to applicable law, you are not required to answer YES to these questions. If you are unsure
whether to answer “yes”, we strongly suggest that you answer YES and fully disclose all incidents. By doing so, you can avoid
any risk of disciplinary action or revocation of your offer of admission.
☐ Yes
☐ No
Terms and Conditions
☐ By selecting this box, I state that I have read and understood this brochure and agree to abide by the Terms and
Conditions.
Payment of Fees
☐ By selecting this box, I agree to pay all tuition and accommodation fees incurred by the student as they become due.
Authorization for Release of Information
☐ By selecting this box, I agree that SCSU and the OIE (to the extent it may be covered by FERPA) may release my student
record as necessary to facilitate admissions, enrollment and continued progress through any academic program at SCSU. This
authorization specifically permits the sharing of information between SCSU and any other entity directly responsible for my
recruitment or continued participation in the SCSU ESL Program.
Students 18 and older:
SIGNED:
Date:
Month
Student’s Name:
/ Day
/
Year
(Please Print)
Students under 18:
All students under the age of 18 must have all applications and contracts signed by a parent/guardian or sponsor.
SIGNED:
(Parent/Guardian/Sponsor – if student is under 18)
Parent/Guardian/Sponsor:
Date:
Month
/ Day
/
Year
(Please Print)
FINANCIAL INFORMATION:
Declaration of Finances: As a participant in the ESL program, you must pay program and housing costs for the duration of
your stay. Below are estimates of the additional funds you will need while studying at SCSU. The United States Citizenship
and Immigration Services (USCIS) require international students to verify sufficient financial resources at least equal to the
estimate provided below. Before issuing documents which will enable you to obtain your visa, we must have the information
requested below.
I plan to live:
☐ on-campus
☐ off-campus (independently)
☐ off-campus with current U.S. resident*
*If you plan to live with a current U.S. resident or sponsor, please have him or her complete the affidavit of support
on the following page.
Marital Status:
☐ Single
☐ Married
Will any of your dependents (spouse or children) come to the U.S. with you?
☐ Yes
☐ No
How many?
Please provide the following information for each dependent that will arrive with you:
Attach additional sheets as necessary
Name:
Last (Family Name)
First (Given Name)
Date of Birth:
Middle
Native Language:
Gender:
Country of Birth:
Month
☐ Male
/ Day
/
Year
☐ Female
Country of Citizenship:
Country of Legal Permanent Residence:
Certification of Financial Support
Source of Funding
Required Documentation
Personal Bank Statement
(checking/savings)
Certified bank letter/bank statement
Parent(s)/Sponsor(s)
Affidavit of Support (attached) and
certified bank letter/bank statement
Government Agency (home country)
Letter of Award
U.S. immigration law requires Southern Connecticut State University to verify
that any student seeking an F-1 Visa has sufficient funds to finance their
studies for the duration of their program.
If it is determined that you are admissible to the SCSU ESL Program, we will provide
you with an I-20 (or other eligibility document) only after you have submitted
satisfactory evidence that you have adequate funds for your proposed program of
study. Acceptable financial documents must not have been issued more than six (6)
months before the date you intend to enroll in the SCSU ESL Program, and must
accompany this form.
Additional Support Needed for
Dependents
If you have a spouse or child(ren)
that will accompany you to the
United States, you must include a
minimum of an additional
$5,000 per year for your spouse,
and $5,000 per year for each
additional dependent. Please
note that this estimate for
dependents is the minimum
amount you must show. If
purchasing insurance in the U.S.
for dependents, actual costs will
likely increase.
CERTIFICATION AND SIGNATURE:
I certify that all statements on this form are true and accurate information and that the stated funds are available for my
educational expenses at Southern Connecticut State University during the period specified. I will notify SCSU of any
changes in my financial circumstances. Furthermore, I understand that under the Privacy Act, the information I have
given cannot be shared with anyone except me and SCSU without my written permission.
SIGNED:
Student’s Name:
Date:
(Please Print)
Month
/ Day
/
Year
Affidavit of Support
I,
hereby certify that I am willing and able
(Print full name of family member/personal sponsor)
to provide the amount of $
in U.S. dollars to meet the expenses incurred by
during the length of the student’s study to which
(Print student’s full name)
their application pertains.
My relationship to the student is that of:
. I have authorized the release of my supporting
financial documents to verify that the promised financial resources are available to me. I affirm that I know and understand
the contents of this affidavit signed by me and that the statements are true and correct.
SIGNED:
Date:
Month
Sponsor’s Name:
(Please Print)
/ Day
/
Year