Depauw University Exchange Student Release of Information
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EXCHANGE PROGRAM APPLICATION Fall 2017-Spring 2018 APPLICATION DEADLINES One year exchange program: March 1, 2017 (program begins August 2017) Fall (August-December) Semester only: March 1, 2017 Spring (January-May) Semester only: October 2, 2017 CHECKLIST—REQUIRED APPLICATION MATERIALS Exchange Program Application Personal Essay (see instructions below) One (1) passport-size photo Original official university transcript Copy of passport identification page Original bank statement TOEFL score report (minimum required score: 563 PBT, 223 CBT, 85 IBT with at least at 20 in each Writing, Reading, Speaking & Listening) or IELTS score report (minimum required score: 6.5) Mail completed application to: Admission Office c/o Loutfi Jirari P.O. BOX 37. Greencastle, Indiana 46135 USA PERSONAL INFORMATION Full legal name: __________________________________________________________________ Family name Given name Middle, if any Prefer to be called _________________________________________________________________ Home address: __________________________________________________________________ Number, street, apartment __________________________________________________________________ City State/Province Postal code Country DePauw University: 2017-2018 Exchange Student Application Mailing address, if different from above: __________________________________________________________________ Number, street, apartment __________________________________________________________________ City State/Province Postal code Country Home telephone: +________________________ Fax number: + ________________ (if available) Personal (permanent) e-mail address: ________________________________________________ School-issued email address (if applicable): ________________________________________________ Sex: Female / Male Date of birth: __________________ Place of birth: ______________________ month / day / year City Country Country (countries) of citizenship: ______________________________________________________ Are you applying for DePauw’s Language Department Assistant program? Yes / No If yes, please indicate the language program which you would like to support (circle one): Spanish French German Italian Japanese Chinese All language(s) spoken: 1. _________________________ Circle option that best describes your fluency level in this Language language): Fluent Advanced Intermediate Beginner 2. _________________________ Circle option that best describes your fluency level in this Language language): Fluent Advanced Intermediate Beginner 3. _________________________ Circle option that best describes your fluency level in this Language language): Fluent Advanced Intermediate Beginner Travel experiences (location and length of trip): __________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ EDUCATIONAL INFORMATION Most recent university attended: ________________________ Dates attended: _______________ 2 | P a g e DePauw University: 2017-2018 Exchange Student Application Other universities or special programs attended, with dates: _________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Major field(s) of study at home university: __________________ Minor(s): ____________________ Possible career goal(s): ______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Courses you intend to take at DePauw (refer to the “Schedule of Classes https://my.depauw.edu/e/reg/soc-view/): Department Course Title Instructor Required for Number major/degree? 1. 2. 3. 4. If you are a degree-seeking student (Kansai Gaidai University, only), which of the majors offered at DePauw do you intend to declare: _____________________________________________________ Please review the list of available majors here: http://www.depauw.edu/academics/departments- programs/ Official TOEFL score and date taken (if applicable): ________________________________________ Section Score (applicants must have a score of at least 20 for each section) Speaking Listening Reading Writing (Note: Only test results issued within the last two years will be accepted for this application process.) IELTS score and date taken (if applicable): _______________________________________________ (Note: Only test results issued within the last two years will be accepted for this application process.) 3 | P a g e DePauw University: 2017-2018 Exchange Student Application FAMILY CONTACT INFORMATION Mother/Guardian ___________________________________________________________ Family name Given name Middle, if any E-mail address: _______________________ Home telephone number: _____________________ Home address, if different from yours: _________________________________________________________________________________ Number, street, apartment _________________________________________________________________________________ City State/Province Postal code Country Occupation: ______________________________ Work telephone number: _________________ Father/ Guardian Prefers to be addressed as (Dr., Hon., Mr., Rev., Other) _________________________________________________________________________________ Family name Given name Middle, if any E-mail address: _______________________ Home telephone number: _______________________ Home address, if different from yours: _________________________________________________________________________________ Number, street, apartment _________________________________________________________________________________ City State/Province Postal code Country Occupation: ______________________________ Work telephone number: __________________ EXTRACURRICULAR INFORMATION Activities: ________________________________________________________________________________ Honors and prizes: ________________________________________________________________________ Athletic involvement: ______________________________________________________________________ Volunteer and service experience: ____________________________________________________________ Employment experience: ____________________________________________________________________ Religion/Faith practices: (optional) ____________________________________________________________ 4 | P a g e DePauw University: 2017-2018 Exchange Student Application HOUSING PREFERENCES: I will apply for housing (please check one); Floor-type preferences: For the entire 2017-2018 academic year Single gender For only the Fall 2017 semester Coed (mixed genders) For only the Spring 2018 semester I prefer the following living arrangements: Traditional Upper Class Housing (with meal plan) Reese Hall (suite-style living with upper class students, single room, and partial meal plan University owned apartment or house (single or shared rooms with upper class students, no meal plan required) Please indicate your room preference: Single Double Triple Do you smoke? Do you object to having a roommate who smokes? Yes Yes No No 5 | P a g e DePauw University: 2017-2018 Exchange Student Application PERSONAL ESSAY—INSTRUCTIONS This personal statement helps us become acquainted with you in ways different from courses, grades, test scores, and other objective data. The essay will demonstrate your ability to organize thoughts and express yourself. We are looking for an essay that will help us get to know you better as a person and as a student. Please write and type an essay (250-500 words) on the following topic and include it with your completed application materials: A range of academic interests, personal perspectives, and life experiences adds much to the educational mix. Given your personal background, describe an experience that illustrates what you would bring to the diversity in a college community, or an encounter that demonstrated the importance of diversity to you. (This topic was taken from the 2006 Common Application, Inc.) SIGNATURE My signature certifies that, to the best of my knowledge, the information I have provided on this application and in supporting documentation is accurate and complete. I understand that these application materials are confidential and will not be released to me or to any other person, except as provided by law. Applicant’s signature:_______________________________________________ Date:_________________ Exchange Partner Representative Signature: ________________________________________________________ Date:_________________ Exchange Partner Representative contact information Name: Mr. / Ms. ____________________________________________________________________________ Given name Middle name (if any) Family name Title:_________________________________________ Email address:________________________________ 6 | P a g e DePauw University: 2017-2018 Exchange Student Application DePauw University Exchange Student Release of Information I authorize and request the appropriate officials at DePauw University to report my registration, courses, credits and grades to my Exchange Program Coordinator at my home institution each academic term as long as I am on an established exchange program through DePauw University and my home institution. These reports are to be addressed to the Exchange Program Coordinator: Name: __________________________________________________ Title: __________________________________________________ Office: __________________________________________________ University: __________________________________________________ Street Address: __________________________________________________ City: __________________________________________________ Country and Postal Code: __________________________________________________ Signature: ______________________________________ Date: _______________ Printed Name (block letters): ___________________________________________________ 7 | P a g e .