International Student Information


(August 2012)
Please provide all information requested. Print very clearly to help us avoid errors. Thanks!
















Date


CWID #


Social Security #


SEVIS #












Gender________
Family Name (Surname)

First (Given) Name
Middle/Other names



















Local Residence Address (not your P.O. box!)

C/S P.O. Box
Residence Phone
Office Phone
E-mail Address





Second E-mail Address






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IF YOU HAVE AN EMERGENCY, WHOM CAN WE CONTACT IN THE U.S.?















Name





Relationship to you

His/Her e-mail address















His/Her phone number(s)

His/Her complete address in the U.S.
******************************************************************************************************************************************************************
YOUR RESIDENCE ADDRESS AND CONTACT
LEGAL DATA:



INFORMATION IN YOUR HOME COUNTRY:

Date of Birth (month/day/year): ______/________/_____________
Address:





Place of Birth:








































State/Province

Country
Phone:













Country of Citizenship:



Fax:














Country of legal residence:




Emergency contact:












Passport# & information:














Phone #

E-mail address


______________












Country Issued (mo/day/year) Will Expire (mo/day/year)
*********************************************************************
PERSONAL/FAMILY DATA:



Entry visa: ________ ___________________________








Visa type Visa number
Marital Status:  Single  Married  Divorced









_____________________ __________________ __________________
If married, provide information about spouse:

Which U.S. Consulate? Issued (mo/day/year) Expires (mo/day/year)

Name:





Current Non-immigrant Status:


Citizen of: ____________ DOB (mo/day/year):

I-20/DS-2019 Start Date (mo/day/year): _____/_____/________







Information about children, if any:


I-20/DS-2019 End Date (mo/day/year): _____/_____/________










Name

DOB (mo/day/year) Citizenship
I-94#:













Port of Entry












If you are a transfer student, name previous school:






























Degree Program at MINES:  B.S.  M.S.  Ph.D.
**********************************************************************
Major:






REMARKS (for office use only):


Academic Advisor:












Research Advisor:












Sources of funding:





















Document Outline