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7250 Mesa College Drive, San Diego, CA 92111-4998 (San Diego Mesa College)

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Below are items needed to ensure that your International Student application is complete. Submit only ORIGINAL
documents; NO COPIES, FAXES, OR EMAILS WILL BE ACCEPTED. Complete applications are reviewed by the committee
in the order received. Partial applications will not be considered. Allow up to 5 weeks after the published deadline for
application review before contacting Admissions. Spring 2020 Applications are currently being accepted until the
deadline - October 15, 2019.
BEFORE MAILING YOUR APPLICATION CONFIRM YOU HAVE COMPLETED THE FOLLOWING:
☐ International Student Application Form (2 pages) w/Passport Photo attached
☐ Financial Statement
☐ Health Examination Report
☐ Application Fee Payment Form
☐ Transfer Clearance Form (if transferring from a U.S. school)
In addition to application packet above, include the following supplemental documentation:
☐ Copy of biographical passport page
☐ Copy of visa
for students currently in the United States
☐ Official TOEFL Scores requested from ETS
send to San Diego Mesa College (school code 4735)
☐ Official High School Transcripts showing proof of graduation (translated)
☐ Official US College or University Transcripts (if applicable)
☐ Comprehensive Evaluation of Foreign College or University Transcripts (if applicable)
☐ Mail or deliver all original and complete forms to the following address: San Diego Mesa College, International
Students | Admissions, 7250 Mesa College Drive, San Diego, CA 92111-4998. Only after acceptance a
Form I-20 is issued.
☐ If accepted, I will attend the 4-day mandatory orientation on January 13 to January 17. I understand failing to attend
the 4-day mandatory orientation will result in a cancellation of my Form I-20 and admission.
International Student Program
Application Checklist
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
TYPE OR PRINT IN BLUE OR BLACK INK ONLY. FALL SEMESTER SPRING SEMESTER _________________
YEAR
NAME IN FULL (AS IT APPEARS ON PASSPORT):
____________________________________________ __________________________________________ _________________________________________
SURNAME/PRIMARY/LAST NAME GIVEN/FIRST NAME MIDDLE NAME
CURRENT U.S. CONTACT INFORMATION (IF AVAILABLE):
__________________________ _____________________________________________________________ _________________________________________
STREET NUMBER STREET NAME CITY
_____________________________________ ______________
UNITED STATES___ U.S. PHONE NO.: (_________)_________________________
STATE ZIP CODE COUNTRY AREA CODE + NUMBER
E-MAIL ADDRESS: __________________________________________________________________________________________________________________
ENGLISH PROFICIENCY: WHAT IS YOUR LANGUAGE OF INSTRUCTION: ENGLISH IF NOT ENGLISH PROVIDE THE SCORE/GRADE FOR
ONE OF THE FOLLOWING: TOEFL IELTS U.S. ENGLISH COMPOSITION COURSE _________________ ______________________
SCORE/GRADE DATE COMPLETED
EDUCATIONAL GOAL: _______________________________________________________________________________________________________________
MAJOR
ASSOCIATE DEGREE ASSOCIATE DEGREE AND TRANSFER FOR BACHELOR’S DEGREE* TRANSFER ONLY FOR BACHELOR’S DEGREE*
*IF YOU PLAN TO TRANSFER TO ANOTHER COLLEGE AFTER SAN DIEGO MESA COLLEGE, PLEASE INDICATE THE INSTITUTION(S) YOU ARE CONSIDERING:
___________________________________________________________________________________________________________________________________
COLLEGE/UNIVERSITY
BIOGRAPHICAL INFORMATION:
DATE OF BIRTH: __________________________________ COUNTRY OF BIRTH: ___________________________________________________________________
MONTH/DAY/YEAR
COUNTRY OF CITIZENSHIP: ________________________________________________________________________ GENDER: FEMALE MALE
PASSPORT NUMBER: ________________________________ HOME COUNTRY PHONE: __________________________________________________________
COUNTRY CODE + NUMBER
COMPLETE HOME COUNTRY ADDRESS: ____________________ ____________________________________________________ ________________________
STREET NUMBER STREET NAME CITY
_________________________________________ _________________________ ______________________________________________________________
PROVINCE/ TERRITORY/STATE POSTAL/ZIP CODE COUNTRY
MARITAL STATUS: SINGLE
MARRIED* COMPLETE BELOW AND SEE ADDITIONAL REQUIREMENTS ON THE FINANCIAL STATEMENT FORM.
*IF ANY DEPENDENTS WILL BE TRAVELING WITH YOU TO THE UNITED STATES YOU MUST ATTACH A COPY OF THEIR PASSPORT(S). PLEASE LIST THEIR NAME,
RELATIONSHIP (SPOUSE OR CHILD), COUNTRY OF BIRTH AND COUNTRY OF CITIZENSHIP HERE:
______________________________________________________________________________________________________________________________________
ARE YOU CURRENTLY IN THE UNITED STATES? NO, continue to Page 2. YES, answer the following:
DATE OF LAST U.S. ENTRY: _________________ VISA STATUS (B, E1, E2, F1, F2, J ETC.): __________ I-94 EXPIRATION DATE: _________________
MONTH/DAY/YEAR MONTH/DAY/YEAR
ARE YOU REQUESTING AN INITIAL ATTENDANCE-CHANGE OF STATUS FORM I-20 TO OBTAIN YOUR F-1? YES NO, I ALREADY HAVE F-1 STATUS OR NO, I
WILL RETURN TO MY HOME COUNTRY TO OBTAIN MY F-1 VISA.
International Student Program
Student Application
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619) 388-2717
ATTACH
PASSPORT
SIZED PHOTO
HERE
PREVIOUS SCHOOLS AND COLLEGES ATTENDED
List all secondary/high schools and colleges attended and all diplomas or certificates earned at these schools. Do not list
schools attended prior to high school.
REQUIRED: OFFICIAL TRANSCRIPTS WITH ENGLISH TRANSLATION FROM HIGH SCHOOL AND ALL COLLEGE/UNIVERSITIES ATTENDED.
ATTENDANCE DATES:
FROM TO
Month/Year Month/Year
NAME OF SCHOOLS
AND
COUNTRY
TYPE OF DIPLOMA,
DEGREE, CERTIFICATE
EARNED
GRADES
EARNED
OR GPA
________ TO _________
NAME
*
MUST SUBMIT PROOF OF
GRADUATION/COMPLETION
CURRENTLY ATTENDING?
YES
NO
COUNTRY
________ TO _________
NAME
CURRENTLY ATTENDING?
YES
NO
COUNTRY
________ TO _________
CURRENTLY ATTENDING?
YES
NO
NAME
COUNTRY
*An international student in possession of an associate degree or its equivalent (completion of about 60 semester units), or higher
may be determined to be beyond the course offerings of Mesa college and is encouraged to apply to a four-year college or university.
EMERGENCY CONTACTS
Please provide names of anyone you wish to authorize to obtain information about you, your application or your enrollment status, in case of an emergency.
NAME
RELATIONSHIP
PHONE NUMBER
______________________________________
____________________________________
____________________________________
LAST NAME, FIRST NAME
____________________________________
PARENT/SIBLING/FRIEND/ETC
____________________________________
AREA CODE, FOLLOWED BY NUMBER
____________________________________
LAST NAME, FIRST NAME PARENT/SIBLING/FRIEND/ETC AREA CODE, FOLLOWED BY NUMBER
BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ADMISSIONS INFORMATION IN ITS ENTIRETY.
I declare under penalty of perjury that all information provided refers specifically to me and is true and correct. I understand that falsification
or withholding information requested on this form shall constitute grounds for denial. In the event of a denial, San Diego Mesa College
reserves the right to refrain from disclosing information pertaining to your admissions status.
☐ If accepted, I will attend the 4-day mandatory orientation (approximately three weeks before the start of the semester). I understand failing
to attend the 4-day mandatory orientation will result in a cancellation of my Form I-20 and admission.
Name of Applicant (PLEASE PRINT): _________________________________________________________________________________________
Signature of Applicant: _________________________________________________________________ Date: _____________________________
Certify you have available (within the past 30 days) liquid funds in a US or foreign bank account to cover the first
year of tuition and expenses at Mesa College in the amount of USD $27,000. If you are not funding your own
studies, obtain signatures of all sponsors who can certify they will cover your expenses. The estimates we provide
are based on the applicant being single with no dependents.
If you have dependents: please add an additional $9,000 per spouse or child accompanying you to the United
States.
SPONSOR CERTICATION:
I CERTIFY THAT I WILL BE RESPONSIBLE FOR THE FINANCIAL SUPPORT OF THE APPLICANT AS SHOWN IN THE STATEMENT BELOW.
Name
(PLEASE PRINT)
Signature of Sponsor
Relationship to
Applicant
Financial Source
(Personal Funds,
sponsor, or government)
Total
Financial
Support
Total support in USD:
(minimum USD $27,000)
$
SELECT A OR B:
FOR EACH SPONSOR LISTED ABOVE, SUBMIT THE FOLLOWING CERTIFICATIONS BELOW:
A.
BANK CERTICATION
(BANK OFFICIAL ONLY)
I certify that I have read the information given by the applicant on this form. It is true and accurate and the funds are
available as indicated.
Name of Bank: ______________________________________________________________________________________
Address of Bank: _____________________________________________________________________________________
Bank Official’s Name: ___________________________________________
(PLEASE PRINT)
Bank Official’s Title: ____________________________________________
(PLEASE PRINT)
Bank Official’s Signature: _______________________________________
Date: _________________________________
B.
Provide an official Certificate of Balance, issued by the bank, for applicant or sponsor listed above.
In lieu of Certificate of Balance, attach most recent original bank statement, stamped by a bank official.
I certify that I have sufficient financial support as indicated above to pay for my studies while attending San Diego
Mesa College.
Name of Applicant (PLEASE PRINT): _______________________________________________________________________
Signature of Applicant: ___________________________________________ Date: _____________________________
International Student Program
Financial Statement
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
PLACE OFFICIAL STAMP/ BANK SEAL HERE
International Student Program
Health Examination Report
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619) 388-2717
Name: _____________________________ _________________________________ _________________________
(PLEASE PRINT) LAST FIRST MIDDLE
Country of Birth: _______________________________ Country of Citizenship: _______________________________
PART A. MEDICAL HISTORY: (TO BE COMPLETED BY STUDENT APPLICANT)
Have you had or do you now have any of the following conditions? If yes, give approximate dates:
AIDS/HIV (
Human Immune Deficiency Virus
)
Depression
Malaria
Thyroid Problems
Allergy (severe)
Epilepsy Diabetes
Measles (rubeola)
Tuberculosis
Anemia
Epilepsy
Meningitis
Stomach Ulcer
Anxiety
Heart Problem (restrictions)
Migraine Headaches
Other conditions (including but not
limited to learning disabilities):
_____________________
Asthma
Hepatitis
Mononucleosis
Bipolar Disorder
High Blood Pressure
Polio
Blackouts
Intestinal Problems
Rheumatic Fever
Chicken Pox
Kidney Disease
Rubella
Any complications/restrictions due to the above conditions: NO YES, explain below:
___________________________________________________________________________________
Do you have any conditions that would affect your ability to enroll in a full time course load of study? NO YES, please
list conditions and limitations:
_________________________________________________________________________________________
Give date and types of serious operation or injuries: _____________________________________________________
I understand that falsification or withholding information on the Health Examination report shall constitute grounds for denial of
my application.
Applicant Signature: _______________________________ Date: ___________________________
PART B. MEDICAL CERTIFICATION: (TO BE COMPLETED BY PRIMARY CARE PROVIDER-PCP)
Current immunization and tuberculosis clearance with dates specified must be completed and verified before acceptance to
San Diego Mesa College.
1. Tetanus (
must be within the past nine years
). Date: ___________________
2. Measles (rubeola), Mumps, Rubella (
must be given after 1970 and after 12 months of age
).
Measles (rubeola) Date: ___________________ Mumps Date: ____________________ Rubella Date: ______________
3. Polio Date: ___________________ Diphtheria Date: ___________________
4. BCG inoculation Date: ________________________
If no BCG documentation, Tuberculosis clearance, dated within the past three months of the physical exam, complete
one of the following:
QuantiFERON blood test Date: ___________________ Result:___________________________________
Mantoux skin test Date: ___________________ Result*:___________________________________
*If Mantoux test is positive, chest x-ray is required.
Chest X-ray Date: ___________________ Result*:________________________________
*Attach copy of your chest x-ray report. Do not send the x-ray film.
Does student have any conditions which would affect the student’s ability to perform in an academic setting? No Yes,
explain:________________________________________________________________________________________
Special Health Problems, including conditions that would limit full-time study:
___________________________________________________________________________________________________________
I have examined _________________________________________and I find him/her in good health and able to attend college.
STUDENT NAME
Signature of PCP : ______________________________ Date: ____________________
Name of PCP: ___________________________________________________________
PLEASE PRINT
Address _____________________________________________________________
Email:_______________________________________________________________
Phone Number: _________________________ PCP Stamp or Business Card
For Official Use Only:
CSID____________________________
PLEASE DO NOT SEND CASH. If not paying by credit card, attach an international or US money order.
Make money order payable to San Diego Mesa College.
Student’s Name (
PLEASE PRINT): _________________________________________________________________________
ACCEPTING ONLY VISA AND MASTERCARD.
VISA
MASTERCARD
CARD HOLDER’S NAME (AS IT APPEARS ON THE CARD): _________________________________________
16 DIGIT CREDIT CARD NUMBER: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
SECURITY CODE (3 OR 4 DIGIT CODE ON THE BACK OR CARD): ___ - ___ - ___ - ___
EXPIRATION DATE: _____________ _____________
MONTH YEAR
BILLING ADDRESS OF THE CREDIT CARD HOLDER:
________________ _____________________________________________ ______________________
NUMBER STREET APARTMENT NUMBER
______________________ _______________________ ________________ ____________________
CITY PROVINCE/ TERRITORY/ STATE POSTAL/ ZIP CODE COUNTRY
I authorize the San Diego Mesa College Accounting Office to charge $100.00 to my credit card as payment for the
non-refundable International Student Program application processing fee.
Cardholder’s Name (PLEASE PRINT): ______________________________________________________________________
Cardholder’s Signature: ________________________________________ Date: ______________________________
International Student Program
Application Fee Payment Form
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
Students who have attended a US institution within the last 5 months must have this form completed by your
Designated School Official (DSO). Once this form is complete please submit this form with your complete application
materials to San Diego Mesa College.
TRANSFER CLEARANCE VERIFICATION (TO BE COMPLETED BY THE DESIGNATED SCHOOL OFFICIAL- DSO)
Name of Student (AS IT APPEARS ON PASSPORT):
___________________________________________ __________________________________________ _______________________________________
LAST NAME FIRST NAME MIDDLE NAME
SEVIS ID#:
N
___ - ___ - ___ - ___ - ___ - ___ - ___ - ___ - ___ -___
Attendance dates at the school: FROM: ___________________________ TO ______________________________
(MONTH/YEAR) (MONTH/YEAR)
Last date (expected last date) of attendance: _____________________ SEVIS Release Date: _________________
(MONTH/DAY/YEAR) (MONTH/DAY/YEAR)
Is the student welcome to continue at your school? _________ Is the student in good academic standing? _______
Is or was the student academically disqualified? _______________________________________________________
Does the student have any financial obligation to your school? ___________________________________________
Has the student maintained full-time status throughout their attendance at your institution? If no, explain
________________________________________________________________________________________________
Type of program taken (English Language, Academic, Vocational/Technical, etc.):
_______________________________________________________________________________________________
Major course of study:
________________________________________________________________________________________________
List type and dates of all practical training authorized:
School Official’s Name
: ________________________________
SEVIS School Number: _______________________
(PLEASE PRINT)
School Official’s Title: _____________________________________ Email Address: ______________________________
(PLEASE PRINT)
Name of School: ________________________________________________________________________________
School Address: __________________ ______________________________________________________ _____________________________________
NUMBER STREET CITY
_______________ ____________________ _____________________
STATE POSTAL/ZIP CODE COUNTRY
School Official’s Signature: ___________________________________________
Date: _________________________________
APPLY SCHOOL SEAL HERE
International Student Program
Transfer Clearance Form
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
Fax to (619) 388-2960
San Diego Community College District-
San Diego Mesa College
(School Code: SND214F00408000)
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Completed 5 September 2020

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