International Student Application Lorain County Community College Office of International Recruitment & Student Support 1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America Telephone: 440.366.4794, Toll Free: 1.800.995.5222, extension 4794, Online: www.lorainccc.edu Personal Information Name: ________________________________________________________________________________________________________
Address in Home Country:_________________________________________________________________________________________
City:________________________________State/Province/Country:___________________________Postal Code:__________________
Day Telephone ( )_________________________________Evening Telephone ( )____________________________________
U.S. Address (if known):__________________________________________________________________________________________
City:_____________________________________________State:__________________Postal Code:_____________________________
Country of Birth: ________________________________________________Date of Birth: ___________________________________
Country of Citizenship/Nationality: _________________________________________________________________________________
U.S. Social Security Number:__________________________________E-mail Address:________________________________________
Enrollment Intentions What Semester Do you Plan to Begin? ❐ Fall (Aug.-Dec.) ❐ Spring (Jan.-June) ❐ Summer (June-Aug.) Year ___________________
Program of Study:___________________________________________ Initial Attendance ❐ Change of Status Requested ❐
School Transfer/School Name:______________________________________________________________________________________
Reinstatement Requested:______yes _______no Other:________________________________________________________________
Driver’s License Number/State of Issue:______________________________________________/________________________________
Language Information Is English your 1st Language______yes ______no
If no, state your 1st language____________________________________________
Current Visa Status If you are currently in the United States, what is your current visa type?___________I-94 Admission Number:________________________
Date of Entry:___________________________________________
Port of Entry:_________________________________________
Do you have a current F-1 visa?_______yes _______no
If yes, institution that issued your I-20 Form_________________________
Have you attend that institution?________yes _______no
Dates of Attendance: from_______ to_______
If yes, you must submit an ISO Report to Lorain County Community College. Over please Housing Will you require housing? ______Yes, I will require housing ______No, I have housing supplied for me while in the United States Education List all schools, colleges and universities you have attended. Send original or certified copies of grade sheets, transcripts, and final diploma or degree results for secondary and post-secondary education. Foreign transcripts must be officially translated into English. How did you learn about LCCC?__________________________________________________________ _____________________________________________________________________________________________ Briefly explain why you wish to study here:_______________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Health Insurance Requirement & Acknowledgement All international students attending LCCC must provide proof of Hospitalization and Accident Insurance for each semester they are attending classes. PROOF OF INSURANCE IS REQUIRED PRIOR TO REGISTERING FOR CLASSES.
I, ___________________________________________ was informed of the International Students Health Insurance Requirements. I willprovide all required documents and understand that if I fail to comply with this requirement, LCCC will not allow me to register for classesuntil I provide all proof of insurance coverage or make arrangements to purchase the health insurance offered by LCCC. Legal Signature I certify that the information I have provided on this application is complete and accurate to the best of my knowledge. I understand that falsifying any part of this application may be cause for refusal of admission, cancellation of admission, or dismissal from LCCC. By signing and dating this application, I agree to abide by the policies and regulations of the college as published in the Lorain County Community College Catalog.
Legal Signature: _________________________________
Parent/Guardian Signature: _________________________________
(Parent/Guardian required only if applicant is under 18 years of age)
lnational Student Financial Statement Lorain County Community College Office of International Recruitment & Student Support 1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America Telephone: 440.366.4074, Toll Free: 1.800.995.5222, extension 4074, Online: www.lorainccc.edu Personal Information (PLEASE TYPE OR PRINT CLEARLY)
Student’s Legal Name: ______________________________________________________________________________
Last/Family Name First/Given Name Middle Name
Date of Birth: ________________________________
U.S. Social Security #: ____________________________
Mailing Address: ___________________________________________________________________________
_________________________________________________________________________________________________
City State/Province/Country Postal Code Telephone Number
Country of Citizenship: _____________________________
Financial Information (ALL AMOUNTS MUST BE STATED IN U.S. DOLLARS) Student Savings
Fill in any amount in your own bank account to be used for expenses. Attach a statement from a bank official to verify that this amount is available in your account. $ ______________
Parent Savings Fill in any amount your parent(s) will provide from their savings. Parent(s) must sign this form and attach a statement from a bank official to verify that this amount is available in the account.
Name of Parent(s): _________________________________________________
Parent’s Signature: _________________________________________________
Parent Funds (Not Savings) Fill in any amount to be furnished by your parents that will not come from savings (example: $200 per month - source father’s salary). Parent(s) must sign this form and attach proof of source of funds (example: letter from father’s employer stating monthly salary).
Name of Parent(s): _________________________________________________
Parent’s Signature: _________________________________________________
Other Source of Funds Fill in any amount to be provided from other relatives, your government, a scholar- ship, or any other source. Attach a statement to verify the amount that will be pro- vided to you.
Source of Funds: _________________________________________________
U.S. Sponsor Fill in amy amount you expect to receive from your U.S. Sponsor. Also indicate support that is not in the form of money (example: room and meals). Sponsor must submit an Affidavit of Support (form I-134)
Name of Sponsor: _________________________________________________
Sponsor’s Signature: _________________________________________________
VerificationHealth Status Verification Form Lorain County Community College Office of International Recruitment & Student Support 1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America Telephone: 440.366.4074, Toll Free: 1.800.995.5222, extension 4074, Online: www.lorainccc.edu International Students Report of Tuberculosis Testing Before you can register for classes at Lorain County Community College, you must bring (DO NOT MAIL) the completed docu- ment below showing that you are free from tuberculosis (TB) to the Office of International Recruitment & Student Support at LCCC. You can obtain a skin test (for a minimal fee) at the County Tuberculosis Clinic located at 9890 South Murray Ridge Road, Elyria. Their hours are as follows:
Tuesdays, Wednesdays, Thursdays & Fridays from 8:00 a.m. to 4:00 p.m.
You must return to the Clinic 48 to 72 hours after your test to have them fill out the information at the bottom of this form. Take this form with you when you go.
If your skin test shows that you have been exposed to TB, the doctor at the Clinic will also get an X-ray of your chest (for a mini-mal fee) and will tell you how often you must have chest X-rays taken while you are a student at Lorain County CommunityCollege. The doctor may also advise you to take a medicine (Isoniazid) to prevent you from developing TB later in life. If youchoose to take the medicine, you can get it (for a minimal fee) from the County Clinic.
If you need further assistance in this matter, please contact the Office of International Recruitment & Student Support at LorainCounty Community College. Our telephone number is 1.800.995.5222 (extension 4074). Testing Verification Student's Name: ________________________________________
Student Number: ___________________________
Date TB Test Given (Mantoux Only): _______________________
Result: ___________________________________
Result of Chest X-ray: ___________________________________
Repeat: _____________________________Months
Isoniazid recommended: _____ yes _____ no
Signed: ________________________________________, M.D.
Date: ____________________________________
Location: ___________________________________________________________________________________________
Return Form Bring this form to the Office of International Recruitment & Student Support at Lorain County Community College Note on X-Rays If an X-ray is done, please sign a release of information form at the TB Clinic so that a copy of the chest X-ray report can be forwarded to LCCC.
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