2012 IVSP Application

WELCOME!
Dear Applicant:
Congratulations! You just took your first step to realizing your dream in participating and becoming a member
of Gallaudet University.
The International Visiting Scholar Program (IVSP) is a one- or two-semester non-degree program designed
for international school personnel, researchers, professionals, and students from other countries not desiring a
degree from Gallaudet University. The IVSP is individually designed to meet the needs of each scholar, in which
the participant can take a class for credit, audit a course, and/or gain practical experience by being exposed to
what is happening at Gallaudet University. There are also great opportunities to do intensive data collection in
acquiring specific information and skills relating to deafness.
As an IVSP student at Gallaudet University, you have the unique opportunity to achieve your personal and
professional goals in a barrier-free environment. Our liberal arts curriculum allows you to develop your
individual skills while preparing you to be a vital part of the increasingly globalized world. We hope you will
soon join our proud and strong community of excellence.
Your application and supporting documents represent who you are and what you have to gain and contribute to
and from our University. We encourage you to take the time necessary to make sure that these documents are a
complete and fair representation of your goals and interest in our IVSP program.
We welcome your application to the IVSP program and are available to assist you throughout the process. Please
contact us at:
+1-202-651-5815 (Voice);
+1-866-957-4317 (Video phone);
+1-202-448-6954 (Facsimile);
cips@gallaudet.edu (E-mail).
Thank you.
MISSION STATEMENTS
Gallaudet University
Gallaudet University, federally chartered in 1864, is a bilingual, diverse, multicultural institution of higher education that ensures the
intellectual and professional advancement of deaf and hard of hearing individuals through American Sign Language and English.
Gallaudet prepares its graduates for career opportunities in a highly competitive, technological, and rapidly changing world.
Center for International Programs and Services
The Center for International Programs and Services at Gallaudet University facilitates global education and international exposure which
enriches the academic and cultural environment at Gallaudet and promotes extensive cross-pollination of ideas.
CONTACT INFORMATION
(202)651-5815 (tty/v)
(202)448-6954 (fax)
CIPS@gallaudet.edu
Web: http://cips.gallaudet.edu/
Residence Life - Housing
(202)651-5611(tty)
(202)651-5255 (v)
(202)651-5757 (fax)
Residence.Life@gallaudet.edu
Web:
http://www.gallaudet.edu/Student_Affairs/Residence_Life.html
Student Health Services

(202)651-5090 (tty/v)
(202)651-5743 (fax)
SHS@gallaudet.edu
Web: http://www.gallaudet.edu/shs.html
Gallaudet University is an equal opportunity employer/educational institution and does not discriminate on the basis of race, hearing status,
disability, religion, color, national origin, age, sex, covered veterans status, marital status, personal appearance, sexual orientation, family responsibilities,
matriculation, political affiliation, source of income, place of business or residence, pregnancy, childbirth, or any other unlawful basis.
APPLICATION INFORMATION AND CHECKLIST

IS THIS APPLICATION RIGHT FOR YOU?
You should apply for international undergraduate or graduate
admission if you are seeking a bachelors, masters or doctorate
degree.
APPLICATION FEE
There is a nonrefundable $50 application fee payable by check
(cheque), international money order, or credit card. The check
must be from a bank in the United States and must show the
United States mailing address of the bank. The check should be
made payable to Gallaudet University.
FINANCIAL AID/SCHOLARSHIPS
FINANCIAL STATEMENT
Financial aid and scholarship opportunities for international
students attending the IVSP at Gallaudet University are not
available. For the most part, international students are not
eligible for federal, state, or university aid or scholarships.
CAMPUS HOUSING
Before applying for on-campus housing, you must complete
your application for admission. Once your application is
complete and are accepted to the program, you will be mailed
your admission packet with On-Campus housing request form
included.
OFFICIAL ACT OR TOEFL TEST SCORES
The IVSP program requires that you are proficient in English.
If the language of academic instruction in your country does
not utilize the English language, submit at least one ACT or
TOEFL or IELTS score set with your application.
OFFICIAL HIGH SCHOOL TRANSCRIPT
You must submit official record or transcript documentation
showing that you have completed an accredited secondary
school series equivalent to that of a United States high school.
In order to obtain the immigration document needed to apply

for a student visa, you need to complete and submit the
Certification of Finances Form documenting proof of adequate
financial resources for your stay at Gallaudet University.
Financial documents must be dated and less than 6 months old
indicating value in United States dollars (US$).
STUDENT VISA ELIGIBILITY
The purpose of the Certification of Finances Form is to help
Gallaudet University obtain complete and accurate information
about the funds available for your studies at Gallaudet
University. The United States Citizenship and Immigration
Services (USCIS) regulations require all international
applicants or admitted students to provide evidence of adequate
financial support for their studies in the United States. You are
required to submit both the complete Certification of Finance
Form and original, official documents that show you have
sufficient funds.
Once your Certification of Finances Form is submitted,
reviewed and approved, we will send you the immigration
document, Form I-20 or DS 2019 which you will need to apply
for a visa.
VISA INFORMATION
OFFICIAL UNIVERSITY TRANSCRIPT

If you are currently attending a university or have completed a
degree program from a university, submit an official record or
transcript of all your current and previous academic course
work.
Please allow sufficient time when applying for admission to the

IVSP program, receiving your immigration documents, and
applying for a visa at a United States Embassy in your country.
A reasonable time of between three to six months should be
sufficient. All international students applying for a visa are
required to pay a SEVIS fee. Proof of SEVIS fee payment must
be submitted at the visa interview. More information is
available at: www.ice.gov/sevis/i901.
APPLICATION DOCUMENTS
APPLICATION/CREDENTIAL DEADLINES
Listed below are the items that need to be completed for

admission to the IVSP program at Gallaudet University. Check
to make sure each item has been sent to us. Your application
cannot be reviewed until we receive all items on the list.
Fall Semester
Completed IVSP Application Form

Application Processing Fee ($50)
Your goals statement - Complete both questions on a
separate paper.
High School Transcript (Secondary school transcript

and/or upper school transcript) or University
Spring Semester ....
June 31
October 30
PLEASE NOTE: The application, application fee, and all

supporting credentials must be submitted by these dates. Only
complete applications will be reviewed for admission to the
University. All academic records and supporting documents
must be official. If only one original is available, a copy attested
or certified by the institution may be submitted. A certified,
literal English translation must accompany the original
document if not in English. Please read the instructions on the
following pages carefully and complete all necessary steps.
Transcript(s)
Two Letters of Recommendation - Must be submitted
Please make a photocopy of your application forms, documents,
from teachers, school administrators, employers, or
and essays for your record.
community leaders. Recommendation letters must

describe your academic motivation, leadership potential
and your ability to succeed in a challenging college
environment
Audiogram
An applicant can be admitted to the IVSP without
submitting proof of English language proficiency. However,
to enroll in a college-level course, you must demonstrate
proficiency in English, by meeting any of the following
conditions:
International TOEFL score of 61 (iBT) /173 (CBT)

/500(PBT) or higher.
Academic placement on the Gallaudet University

English Language proficiency examination.
BIOGRAPHICAL INFORMATION
Please print (write in block letters) and as printed on your birth certificate and/or passport)
Mr.
Ms.
Mrs.
Last Name (surname/family name): _________________________________________________________________________________

First Name (Given name): ________________________________________________________________________________________
Middle name (other names): _______________________________________________________________________________________
Gender:
Male
Female
Date of Birth: Month _______ Day _______ Year _______
City of Birth: _________________________________________________
Country of Birth: _____________________________________ Country of Citizenship: _______________________________________

CURRENT MAILING ADDRESS
PERMANENT ADDRESS
Street:
________________________________________________
Street:
________________________________________________
P.O. Box/Apartment Number:

________________________________________________
P.O. Box/Apartment Number:

________________________________________________
City:
City:
________________________________________________
________________________________________________
State/Province:
State/Province:
________________________________________________
________________________________________________
Zip/Post Code:
Zip/Post Code:
________________________________________________
________________________________________________
Country:
Country:
________________________________________________
________________________________________________
Telephone:
Telephone:
________________________________________________
________________________________________________
country code and number

Fax:
________________________________________________

Fax:
________________________________________________
E-mail:
E-mail:
________________________________________________
________________________________________________
FAMILY INFORMATION (Emergency Contact)

FATHER/LEGAL GUARDIAN CONTACTS
Father/Guardian Full Name:
______________________________________________________________________________________________________________
Last name
First name
Middle name
Address:
______________________________________________________________________________________________________________
City:
State/Province:
__________________________________________________________
_____________________________________________
Zip/Post Code:
Country:
___________________________
______________________________________________________________________
Telephone:
FAX:
________________________________________________
______________________________________________________
E-mail: _______________________________________________________________________________________________________
MOTHER/LEGAL GUARDIAN CONTACTS
Mother/Guardian Full Name:
______________________________________________________________________________________________________________
Last name
First name
Middle name
Address:
______________________________________________________________________________________________________________
City:
State/Province:
__________________________________________________________
_____________________________________________
Zip/Post Code:
Country:
___________________________
______________________________________________________________________
Telephone:
FAX:
________________________________________________
______________________________________________________
E-mail: _______________________________________________________________________________________________________
HEARING STATUS
Are you:
Deaf
Hard of Hearing
Hearing?
If Deaf, type of amplification used:
Hearing Aid(s)
Cochlear Implant
None
Age at onset of your hearing loss? _____________ Cause of your hearing loss ________________________________________________
SIGN LANGUAGE INFORMATION

How long have you been using sign language? ________________________________________________________
Please rate your ability to communicate in sign language:
Native
Good
Fair
Poor
None
The amount of time you communicate in sign language:
100%
75%
50%
25%
Never
If you are a new signer and are admitted to the University, would you be interested in attending our New Signers Program (The New
Signers Program is offered only in August.)?
Yes
No
OTHER INFORMATION
Do you plan to live on campus?
Yes
No
How did you find out about our program? (check all that apply)
Alumnus/Alumna
Home visit
Gallaudet View book
Internet
Counselor
Mail
Friend
Newspaper/Magazine
Teacher
While visiting D.C.
Students at Gallaudet University
Family
Visiting faculty/staff from Gallaudet University
vvv
Other (explain): _______________________________________________________________________________________
Have you ever applied to our program before?
Yes
No
If yes, were you accepted?
Yes
No
If yes, did you enroll?
Yes
No
Please list other names used: _____________________________________________________________________

The following information is confidential and will not affect the consideration of your application. It will allow us to better serve your
individual needs. Your response is optional.
Do you have any additional disabilities?
Yes
No
If you have any additional disabilities, Gallaudet Universitys Office for Students With Disabilities (OSWD) would like to serve you.
Please list your disability and the specific needs you may have, such as large print books, mobility training, braille materials, etc.:
______________________________________________________________________________________________________________
________________________________________________________________________________________________________
Make a copy for your records.

Return all forms to: Gallaudet University, Center for International Programs and Services, Washington, DC 20002-3695, USA.
(202) 651-5815; (202) 448-6954 FAX; CIPS@gallaudet.edu.
Page8of18
POST-SECONDARY EDUCATION INFORMATION

EDUCATIONAL BACKGROUND
Begin with most recent school/university attended. Submit official transcript from every school. Photocopies of transcripts will not be
accepted. Allow three weeks mailing time when sending transcripts from other schools/universities to Gallaudet University.
1)
Current School
Department/Faculty Name: _________________________________________________________________________
Address: _________________________________________________________________________________________
City: __________________________________________________ State/Province: _____________________________
Zip/Postal Code_____________________________________ Telephone: _____________________________________
Fax _____________________________ School Contact E-mail: _____________________________________________
Dates Attended: From (month/year): ________________________ To (month/year): ___________________________
2)
Other School
Department/Faculty Name: _________________________________________________________________________

Address: _________________________________________________________________________________________
City: __________________________________________________ State/Province: _____________________________
Zip/Postal Code_____________________________________ Telephone: _____________________________________
Fax _____________________________ School Contact E-mail: _____________________________________________
Dates Attended: From (month/year): ________________________ To (month/year): ___________________________
Send all transcripts and catalogs to:
Gallaudet University
800 Florida Ave. NE
Washington, DC 20002-3695, USA

Page9of18
STATEMENT OF GOALS
Instructions: There are limitations to what grades, test scores, and recommendations can tell us about any applicant. Your answers to
the following questions will help us learn more about you so we can fairly evaluate your academic commitment and readiness for our
program. We hope that in writing these essays you will reflect on your attitudes, values and perceptions. Please answer both questions
completely, using additional paper.
Essay Question One: Write a brief description of your educational background and experiences with Deaf people.
Essay Question Two: Specify your goals and areas of interest (be as specific as possible)
How did you hear about the program?

Page10of18
AUDIOLOGICAL RECORD (to be completed by deaf or hard of hearing applicant only)

PART A:
Gender:
Male
Female
Date of Birth: Month ____ Day ____ Year ____
E-mail:________________________________________________________________________________________________________
If you already have an audiogram that is less than two years, attached it to this form, otherwise, provide this form to your audiologist/doctor
for a new audiology examination.
PART B (to be completed by certified audiologist):
Onset of hearing loss:
Birth
Other___________ Cause:____________________________________________________________
Month/Year
2. Pure tone:
Date
Administrator
Indicated
ISO-ANSI
Standard
1.
Used:
Right Ear
Frequency
Air
Hearing Level
Bone
Left Ear
Frequency
Air
Hearing Level
Bone
125
250
500
700
1000
2000
3000
4000
6000
8000
125
250
500
700
1000
2000
3000
4000
6000
8000
Name: _____________________________________________________ Title/Position: _______________________________________

Agency: _______________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________
City: __________________________________________________________________________________________________________
State/Province: ________________________________________________ Zip/Postal Code __________________________________
Telephone: ___________________________________________ Fax: _____________________________________________________
E-mail:________________________________________________________________________________________________________

Page11of18
APPLICANT CERTIFICATION
I understand that falsifying or withholding information in completing this application may result in the cancellation of my admission to
the IVSP Program and/or registration. I certify that the information provided in this application is true and correct.
Name (please print in block letters): ________________________________________________________________________________
Signature:_________________________________________________________ Date:_______________________________________

Page12of18
APPLICATION PAYMENT
The nonrefundable $50 application fee is required and will not be waived. Applications arriving without the application fee will be
considered inactive and will not be processed.
Bank Check (Cheque) or International Money Order. Checks/money orders must be in US dollars.
(Attach check (cheque) or money order here)

Amount: US $50.00
Payable to: Gallaudet University
Credit Card. If you wish to pay by credit card (Visa or Master Card only), complete all information below.
Credit Card Type:
VISA
Master Card
Amount; US $ 50.00
Card Number:__________________________________________________ Expiration Date:__________________________________

Name on Account (please print):____________________________________________________________________________________
Card Owner Signature:______________________________________________ Date:_________________________________________

Page13of18
CERTIFICATION OF FINANCES
2012 - 2013 Academic Year
The United States Citizenship and Immigration Services regulations require all international student applicants to provide
evidence of adequate financial support before they may obtain a student visa. To demonstrate that you have adequate financial
support, you must complete and send this form and original, official documents that show you have sufficient funds to pay at least
the fixed/estimated costs of one semester or two semesters. Listed below are the fixed/estimated costs for international students in
the undergraduate and graduate programs at Gallaudet University.
Fixed University Costs for Academic Year 2012-2013 (August 2012 - May 2013)
Tuition
Health Insurance & Service Fee
Unit Fee
Room & Board
Books & Supplies
TOTAL (one academic year)
Undergraduate Program
$24,860.00*
$2,200.00
$276.00
$10,790.00
$1,000.00
$39,126.00
Graduate Program
$27,360.00*
$2,200.00
$276.00
$10,7900.00
$1,000.00
$41,626.00
*This reflects the international surcharge at 100%. This tuition is mandated by the U.S. Government.
Note: This information is provided as a guide only and is not considered a contract or as binding on the University. The
University reserves the right to change tuition costs, fees, and other charges at any time without notice.
Estimated Additional Costs: You should plan to have at least $2,000 for personal expenses each academic year. If you plan to stay
at Gallaudet through the winter and summer vacation periods, you will need an additional $3,000. If your family will stay with
you while you are a student, plan an additional $5,000 for your spouse and $3,000 for each child.
Summer School: Gallaudet offers additional courses during summer school (May-August). Most academic programs do not
require students to take summer school courses. Summer school courses require additional tuition and fees. Consult the Student
Accounts office for a list of these additional charges.
Documentation of Financial Support: Listed below are the sources of support you can use to demonstrate adequate financial
support. The total amount of funds shown in these supporting documents must equal or exceed the fixed costs for one academic
year in your chosen program (see table above). You must obtain two original, official copies of each supporting document.
Attach one copy of each document to this Certification of Finances Form and send it to Global Education and Scholar Services
(GESS) at Gallaudet University. When your documents are received and approved, GESS will send you a completed Form DS2019. You will take the Form DS-2019 AND your second official copy of the supporting documents to the United States Embassy
or Consulate in your country to apply for your student visa. Canadian students do not need a student visa.

Page14of18
CERTIFICATION OF FINANCES
2012 - 2013 Academic Year
Please Type or Print Clearly - This information will be used for your DS-2019
Full Legal Name:
Mr.
Ms.
Mrs.

Male
Gender:
Female
Date of Birth: Month ______ Day ______ Year ______
City of Birth: ____________________________________________________
Country of Birth: ______________________________________ Country of Citizenship: ______________________________________

Mailing Address: _______________________________________________________________________________________________
Number/Street
______________________________________________________________________________________________________________
Number/Street2
______________________________________________________________________________________________________________
City
State/Province
Zip Code/Postal Code
Country
Phone: ___________________________________________________ Fax: _________________________________________________

area code/country code & number
area code/country code & number
E-mail: _______________________________________________________________________________________________________
Start date you expect to start your IVSP program: _______/_______/______ (mm/dd/yyyy)
End date you expect to complete your program: ______/_______/_______ (mm/dd/yyyy)
VISA INFORMATION (if you are already in the United States):

If you are currently on a F-1 or J-1 status at another institution in the U.S., your status is:
F-1 (I-20)
J-1 (DS-2019)
College Name: __________________________________________________________________________________________________

Please enclose photocopies of the following documents.
Passport and Visa Stamp in passport
I-94 Card (both sides)
Form DS-2019 or I-20 or other immigration documents (both sides)

Will you request Gallaudet University to issue the Form DS-2019 or I-20?
Yes
No
If yes,
F-1 or
J-1

Page15of18
CERTIFICATION OF FINANCES Continued

Indicate below your sources of financial support, OTHER than from Gallaudet University, and attach documentation from each
source. The period covered can be for more than one semester.
Source
Amount
Required Documents
Available
Student Funds
1. Bank statement for checking, savings and/or accessible accounts

2. Certificates of deposits, mutual funds, stocks or bonds
Support Available from Family/Friends
1. Complete the Sponsors Affidavit of Annual Cash Support

2. Bank statement for checking and/or savings
3. Certificates of deposits, mutual funds, stocks or bonds.
Support Available from Sponsors
1. Complete the Sponsors Affidavit of Annual Cash Support

2. Official letter from sponsors employer showing annual earnings
Your Government/Embassy
1. Official Letter
Charitable Organizations/School
1. Official Letter
Attach Official Award Letter
Scholarship
OSAP/Canada Students Loan/VR/

$
1. Official Letter
Others (Canadians only)
Applicant Certification
I hereby certify that the total amount of money that I have available for my first academic year at Gallaudet University is
US$____________________. Further, I certify that the information I am providing is correct and complete, and that I will
notify Gallaudet University of any changes in my financial circumstances. I understand that if I am a tourist without a
student visa and/or Form DS-2019, I cannot register as a student at Gallaudet University.
___________________________________________________________
Signature
____________________________________
Date (MM/DD/YYYY)

Page16of18
GUIDE TO SPONSORS AFFIDAVIT OF ANNUAL SUPPORT

What does affidavit mean?
By completing this affidavit, you (sponsor) are sworn to the United States government that you will support with a specific amount of
money from your own financial resources, each year of the students studies and residence at Gallaudet University in the United States of
America. Please note that you also must attach a document with proof to show that you are sworn to support that student every year.
By signing the affidavit, you are making a financial commitment to the student that you must not break. Sponsors who fail to provide the
sworn support will force students to leave school. Do not expect that the student will be able to help support the costs through
employment. Employment is strictly controlled by the Immigration Service and is very limited.
How to complete the enclosed Sponsors Affidavit of Annual Cash Support Form:
Fill out the affidavit form in ENGLISH!

Promise to give only as much money as you can afford. The most common reason we reject affidavits is we do not believe a sponsor
can pay the amount of money as promised.
Attach proof of financial capability document(s) as explained below.

Sign the affidavit in front of a notary public, court registrar or other appropriate official in your country.
Proof of Financial Capability Documents:

You must prove that you are financially capable to support EACH YEAR of your students studies by attaching a proof of income
document and a bank statement. (If one of these documents is not attached, your affidavit will not be considered).
Proof of Income Document. This must be on your employers business stationery, on income tax returns or receipts, or estimates
by a bank with a private account if you are self-employed. The income of your company will not be accepted as proof of income.
You must provide an official statement of the salary paid to you or it must be on your tax returns.
Bank Statement must be in your name and your statement must state the following information: Date when your account was
opened, current balance in U.S. dollars or its equivalent, average deposits and average balances. We cannot accept statements that
do not specify balances unless it is stated to be a minimum of USD 100,000. If another persons name appears on your bank
statement, that person must complete a separate affidavit or submit a notarized statement permitting those funds to be considered as
financial support for the student.
Documents must be:
Current (less than two months old)

In English
Notarized

Page17of18
SPONSORS AFFIDAVIT OF ANNUAL CASH SUPPORT

THIS IS MY SWORN PROMISE OF CASH SUPPORT
I (NAME), _____________________________________________________________________, PROMISE THAT I CAN AND
WILL GIVE NO LESS THAN U.S. $ _______________________________________ IN CASH FOR EVERY YEAR OF THE
STUDENTS PROGRAM OF STUDY AT GALLAUDET UNIVERSITY TO (NAME OF STUDENT):
________________________________________________________________________________________________________
My relationship to the student is ______________________________________________________________________________
My address is _____________________________________________________________________________________________
________________________________________________________________________________________________________
Phone:
___________________________________________ Fax:
___________________________________________
E-mail: _________________________________________________________________________________________________
The following persons are fully or partially dependent upon me for their support. (Do not include the student named above).
Name
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Name of my Employer:
Relationship to me
_________________________
_________________________
_________________________
_________________________
Age
____________
____________
____________
____________
_________________________________________________________________________________
Annual Salary: ___________________________________ (USD) Other Income: _________________________________(USD)

My proof of income document and bank statement is attached:
Yes
No
I swear that the information I have provided above is true and correct.
________________________________________________________________________________________
Signature of Sponsor
Sworn and subscribed before me this day: ______________________________________________________

________________________________________________________________________________________
Signature of Notary Public/Court Registrar

Page18of18

2012 IVSP Application

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2012 IVSP Application

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WELCOME!

Student Health Services

APPLICATION INFORMATION AND CHECKLIST

In order to obtain the immigration document needed to apply

OFFICIAL UNIVERSITY TRANSCRIPT

Please allow sufficient time when applying for admission to the

Listed below are the items that need to be completed for

Completed IVSP Application Form

High School Transcript (Secondary school transcript

Spring Semester ....

PLEASE NOTE: The application, application fee, and all

Two Letters of Recommendation - Must be submitted

Please make a photocopy of your application forms, documents,

from teachers, school administrators, employers, or

and essays for your record.

community leaders. Recommendation letters must

International TOEFL score of 61 (iBT) /173 (CBT)

Academic placement on the Gallaudet University

Last Name (surname/family name): _________________________________________________________________________________

Date of Birth: Month _______ Day _______ Year _______

City of Birth: _________________________________________________

Country of Birth: _____________________________________ Country of Citizenship: _______________________________________

P.O. Box/Apartment Number:

P.O. Box/Apartment Number:

country code and number

country code and number

country code and number

country code and number

FAMILY INFORMATION (Emergency Contact)

country code and number

country code and number

country code and number

country code and number

If Deaf, type of amplification used:

SIGN LANGUAGE INFORMATION

The amount of time you communicate in sign language:

Gallaudet View book

While visiting D.C.

Students at Gallaudet University

Visiting faculty/staff from Gallaudet University

Have you ever applied to our program before?

If yes, were you accepted?

If yes, did you enroll?

Please list other names used: _____________________________________________________________________

Make a copy for your records.

POST-SECONDARY EDUCATION INFORMATION

Department/Faculty Name: _________________________________________________________________________

Make a copy for your records.

How did you hear about the program?

Make a copy for your records.

AUDIOLOGICAL RECORD (to be completed by deaf or hard of hearing applicant only)

Date of Birth: Month ____ Day ____ Year ____

Name: _____________________________________________________ Title/Position: _______________________________________

Make a copy for your records.

Make a copy for your records.

(Attach check (cheque) or money order here)

Card Number:__________________________________________________ Expiration Date:__________________________________

Make a copy for your records.

Make a copy for your records.

Last Name (surname/family name): _________________________________________________________________________________

Date of Birth: Month ______ Day ______ Year ______

City of Birth: ____________________________________________________

Country of Birth: ______________________________________ Country of Citizenship: ______________________________________

Zip Code/Postal Code

Date of Birth: Month ___ Day _ Year _____

Country of Birth: _ Country of Citizenship: ___

Date of Birth: Month Day Year

Name: _______________ Title/Position: _

Card Number:________________ Expiration Date:

Date of Birth: Month Day Year __

Country of Birth: Country of Citizenship:

Phone: ___ Fax: _

Annual Salary: ___ (USD) Other Income: _(USD)