Full Name __________________________________

Family Name __________________________________

Reply Address __________________________________

Nationality _________________________________

Date of Birth (Western Calendar) ___ / ___ / _____

Marital Status ___Single ___ Married___ Divorced

School and University Record: (List in order beginning with primary school from which you graduated and including the university you may now be attending.)

School ________________

City _________________

Major ________________

Dates Attended ___ /___ /_____-___ /___ /_____

School _______________

City _________________

Major ________________

Dates Attended ___ / ___ /_____ – ___ / ___ / _____

School _______________

City _________________

Major ________________

Dates Attended ___ / ___ /_____– ___ / ___ / _____

School _______________

City _________________

Major ________________

Dates Attended ___ / ___ /_____– ___ / ___/ _____

Work in Progress: (subjects, level, when results my be expected)

 

Degrees, Certificates, Diplomas, or other Professional Titles Awarded: (beginning with Matriculation Examination, or its equivalent)

Degree _____________

Date Awarded/Expected ___ / ___ /_____ – ___ / ___ / _____

Division, Rank, Average, or Percentage of Mark Received ____________

Degree _____________

Date Awarded/Expected ___ / ___ /_____ – ___ / ___ / _____

Division, Rank, Average, or Percentage of Mark Received _____________

Degree _____________

Date Awarded/Expected ___ / ___ /_____– ___ / ___ / _____

Division, Rank, Average, or Percentage of Mark Received _____________

Degree ____________

Date Awarded/Expected ____ / ___ /_____ – ___ / ___ / _____

Division, Rank, Average, or Percentage of Mark Received _____________

Objective Tests Taken: (Indicate date each test was taken or when you expected to take it. Also indicate how many times you have taken it.)

TEST

TOEFL

SAT

GRE

DATE (MM/DD/YY)

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

ATTEMPTS

TEST

ATGSB

CEEB

OTHER

DATE

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

ATTEMPTS

Language Spoken at Home ______________

Years of Formal Study of the English Language. _____

Dates
___ / ___ / _____– ___ / ___ / _____

___ / ___ / _____– ___ / ___ / _____

Where _______________

Years of Instruction Through the Medium of the English Language _____

Financial Statement:

Indicate amount of funds in U.S. dollars available each year for your education in the U.S.A. and their source.

Purpose

Amount

Source

Travel

______________

____________________

Maintenance

______________

____________________

Tuition & Fees

______________

____________________

Educational Plan:

I wish to apply for admission as a candidate for a _________degree

In__________

for the term beginning in _____________.

Signature __________________  Date ___ / ___ / _____