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

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

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Country of origin: US
File type: PDF

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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.
GRADES
OR
LEVELS
ATTENDANCE DATES:
FROM TO
Month/Year Month/Year
NAME OF SCHOOLS
AND
COUNTRY
TYPE OF DIPLOMA,
DEGREE, CERTIFICATE
EARNED
GRADES
EARNED
OR GPA
*HIGH SCHOOL
________ TO _________
NAME
*
MUST SUBMIT PROOF OF
GRADUATION/COMPLETION
TRANSCRIPT INCLUDED
CURRENTLY ATTENDING?
YES
NO
COUNTRY
COLLEGE/UNIVERSITY
________ TO _________
NAME
TRANSCRIPT INCLUDED
CURRENTLY ATTENDING?
YES
NO
COUNTRY
OTHER,
LANGUAGE SCHOOL
________ TO _________
CURRENTLY ATTENDING?
YES
NO
NAME
TRANSCRIPT INCLUDED
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.
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: _____________________________
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7250 Mesa College Drive, San Diego, CA 92111-4998 (San Diego Mesa College)

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Completed 5 September 2020

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