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: ______

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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.)

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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) ______

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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

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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:______

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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): ______

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