Fillable Application International Nov 2019 Edit (Gadsden State Community College)

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Application International Nov 2019 Edit (Gadsden State Community College)

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GADSDEN STATE COMMUNITY COLLEGE
P.O. Box 227, Gadsden, Alabama 35902-0227 (256) 549-8324 Fax (256) 549-8344
Homepage: www.gadsdenstate.edu Email address: international@gadsdenstate.edu
APPLICATION PROCEDURES
To apply to Gadsden State Community College / Alabama Language Institute, complete and submit the Application Packet (Documents1-8). For students transferring from
a school in the United States, complete and submit the Application Packet (Documents1-7) and the Transfer Clearance Form (Document 8).
1) ___________ Application for Admission — Complete all blank spaces with the information requested.
2) ___________ Affidavit of Financial Support — Submit evidence of sufficient funds to cover the cost of attending Gadsden State Community College.
Have your financial sponsor complete and sign the affidavit. Signature needs to be certified or notarized. Include an original bank letter
from your sponsor's financial institution, showing the balance in your sponsor's bank account in US dollars.
3) ___________ Medical Records — A medical health history with proof of vaccinations.
4) ___________ Official high school transcript — Send a certified original translated and evaluated copy of the student’s high school transcript & diploma.
(Suggested evaluators: http://www.wes.org/ or http://www.lisano-intl.com/
)
5) ___________ Official university transcript — Submit original or recently certified copy of transcripts from universities you have attended. English
translations are required of any transcripts not in English.
6) ___________ Test of English as a Foreign Language — If applying for college, submit a TOEFL score of 500 (on the paper-based test), 61 (on the internet-
based test), Eiken score Pre-first, or IELTS (International English Language Testing System) test score of 5.5, indicating proficiency
in the English language. An official score must be sent directly to Gadsden State from ETS or IELTS. The TOEFL institutional code
for Gadsden State is 1262. TOEFL or IELTS score is not required for the Alabama Language Institute.
7) ___________ Small photograph of yourself.
8) ___________ A photocopy of the ID page of your passport.
9) ___________ Transfer Clearance Form — To be completed by your International Student Advisor if you are a transfer student from an American
university or college.
Mail all documents together to:
Your application will be carefully evaluated and a decision made. If approved, you will receive an acceptance letter and the 1-20 form. If you wish to have your 1-20 sent by Federal
Express or DHL, it is your responsibility to pay for the charges. The 1-20 form is a legal document and cannot be faxed. You will need to take the 1-20 form to the nearest U.S.
Embassy or Consulate to apply for a student visa. For program information, visit Gadsden State's homepage: www.gadsdenstate.edu
PROGRAM OF STUDY (Short certificates are available also)
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AS - ASSOCIATE IN SCIENCE
GENERAL STUDIES……………………………………. GNST
Areas of Interest* (Concentration Codes):
*AGRICULTURE..............................................….....AGR
*BIOLOGY…………………………………………….. BIOL
*BUSINESS ADMINISTRATION …………………. ..BUSI
CHEMISTRY.…………………………………….…..CHEM
*COMPUTER INFORMATION SYSTEMS …….…….CIS
*COMPUTER SCIENCE SCIENTIFIC ………….…..CSS
* COURT REPORTING………………. ………….…..CRP
*CRIMINAL JUSTICE…………………………….….CRMJ
*DIAGNOSTIC MEDICAL SONOGRAPHY…….…..DMS
*EARLY CHILDHOOD EDUCATION………………ECED
*EDUCATION…………………………………….…..EDUC
*ELEMENTARY EDUCATION………………….…..ELED
*EMERGENCY MEDICAL SERVICES……….……..EMS
*FINANCIAL PLANNING/COUNSELING…………...FPC
*HEALTH, PHYSICAL ED & RECREATION….…..PHED
*HISTORY……………………………………….…….HIST
*MATHEMATICS…………………………………….MATH
*MEDICAL LABORATORY TECHNOLOGY….…….MLT
*MASSAGE THERAPY………………………..……..MSG
*PRE-DENTAL………………………………..……..PDEN
*PRE-ENGINEERING…………………….…….…..PEGR
*PRE-FORESTRY……………………………..……..FOR
*PRE-LAW………………………………………..…...LAW
*PRE-ATHLETIC TRAINING ………………………...PAT
*PRE-MEDICINE………………………………..…..PMED
*PRE-NURSING-ADN 2-YEAR TRACK…………..PNUR
*PRE-NURSING-BSN 4-YEAR TRACK…………...PNUT
*PRE-PHARMACY…………………………………….PPH
*PRE-PHYSICAL THERAPY………………………..PPHT
*PRE-VETERINARY MEDICINE………………...….PVET
*PSYCHOLOGY………………………………………PSYC
*RADIOLOGIC TECHNOLOGY……………...……....RAD
*RELIGION…………………………… ……… ….….RELG
*SOCIOLOGY………………………… ………… ..…SOCI
AA - ASSOCIATE IN ARTS
GENERAL STUDIES……………………………………GNST
Areas of Interest* (Concentration Codes):
*ART………………………………….………………….…..ART
*ENGLISH ...……………………………………………...ENGL
*LIBERAL ARTS………………………………..…….…….LAR
*MUSIC ………………………………….…….……..….MUSC
*PSYCHOLOGY……………………….…………………PSYC
*SPEECH…………………………...…………….………..SPH
NCA - COURSES ONLY
PHLEBOTOMY ……………………………………..……...CLP
ALABAMA LANGUAGE INST………………………..….....ALI
PER ENRICH/TRANSIENT STUDENTS ...………..…....UDA
AAS - ASSOCIATE IN APPLIED SCIENCE
ACCOUNTING TECHNOLOGY………………………..ACCT
CHILD DEVELOPMENT………………………………….CDV
COMPUTER NETWORK ADMINISTRATIVE………….NWA
COMPUTER SCIENCE TECHNOLOGY……………...COMT
DIAGNOSTIC MEDICAL SONOGRAPHY……………...DMS
EMERGENCY MEDICAL SERVICES…………………...EMS
HUMAN SERVICES………………………………….……HUS
MARKETING MANAGEMENT …………………….…. MRKT
MEDICAL LAB TECHNOLOGY ………………….………MLT
OFFICE ADMIN—GENERAL ……………………….……OAD
OFFICE ADMIN-–HEALTH INFORMATION TECH …...OAH
OFFICE ADMIN—MEDICAL CODING/SCRIB……..…..MDS
PARALEGAL…………………………………………….…..PRL
RADIOLOGIC TECHNOLOGY…………………………....RAD
REGISTERED NURSING ………………………………...NUR
CERT – CERTIFICATES
COMPUTER
SCIENCE TECHNOLOTY …………………CST
--BUSINESS COMPUTING TECHNOLOGY…………….BCT
--MICROCOMPUTER REPAIR TECHNOLOGY ………..CIP
--WEB DEVELOPMENT TECHNOLOGY……………….WDV
PRACTICAL NURSING……………………………………PRN
Must have separate acceptance letter:
CRB - Court Reporting Broadcast Captioning
CRP- Court Reporting
DMS – Diagnostic Medical Sonography
EMS – Emergency Medical Services
MSG – Massage Therapy
MLT – Medical Lab Tech
RAD – Radiology
NUR – Registered Nursing
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AAS - ASSOCIATE IN APPLIED SCIENCE
AIR CONDITION & REFRIGERATION.………………. ACR
AUTO MANUFACTURING TECHNOLOGY…………….AUT
CIVIL ENGINEERING TECHNOLOGY………………….CET
ELECTRICAL TECHNOLOGY……………………………ELT
ELECTRONIC ENGINEERING – INDUSTRIAL ………...ILT
ELECTRONIC ENGINEERING-- GENERAL……………EET
INDUSTRIAL AUTOMATION TECH ...…………………...INT
MECHANICAL DESIGN TECHNOLOGY………………..MDT
PRECISION MACHINING TECHNOLOGY……………...PMT
SALON & SPA MANAGEMENT…………………………...SAL
CERT - CERTIFICATES
AIR CONDITION & REFRIGERATION ...……………….ACR
AUTO COLLISION REPAIR………………………………ABR
AUTO MANUFACTURING TECHNOLOGY……………..AUT
AUTOMOTIVE SERVICE. TECHNOLOGY……………..AUM
CIVIL ENGINEERING TECHNOLOGY…………………..CET
DIESEL TECHNOLOGY…………………………………..DEM
ELECTRICAL TECHNOLOGY………………………….…ELT
ELECTRONIC ENGINEERING TECHNOLOGY………...EET
ENGINEERING DESIGN TECHNOLOGY……………….DDT
INDUSTRIAL AUTOMATION TECH……………………....INT
MECHANICAL DESIGN TECHNOLOGY ……………….MDT
PRECISION MACHINING TECHNOLOGY ……………..PMT
SALON & SPA MGM COS TECHNOLOGY ....................SAL
WELDING TECHNOLOGY………………………………..WDT
Rev. 11/7/19
It is the official policy of the Alabama Department of Post-secondary Education including all post-secondary institutions under the control of the board, that no person in Alabama shall, on the grounds of race, color, disability,
sex, religion, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment.
GADSDEN STATE COMMUNITY COLLEGE
DATE OF APPLICATION
NAME (in passport)
LAST NAME / FAMILY NAME
FIRST NAME
MIDDLE NAME
ADDRESS IN YOUR HOME COUNTRY
U.S. MAILING ADDRESS / CONTACT PERSON (IF ANY)
STREET
STREET
APARTMENT #
CITY / STATE / COUNTRY / POSTAL CODE
CITY / STATE / ZIP
AREA CODE / TELEPHONE
TELEPHONE
CELL PHONE
Male
Female
COUNTRY OF CITIZENSHIP:
SEMESTER YOU PLAN TO START:
IF YOU ARE IN THE U.S., LIST TYPE OF VISA STAMPED IN PASSPORT:
IS ENGLISH YOUR FIRST LANGUAGE?
Yes
No (If no, list first and second languages)
IF ENGLISH IS NOT YOUR FIRST LANGUAGE, HAVE YOU EVER TAKEN THE TOEFL TEST?
Yes
LIST HIGH SCHOOL YOU HAVE ATTENDED / GRADUATED:
Date of Graduation
Name of High School
LIST ANY COLLEGES AND/OR POST-HIGH SCHOOL INSTITUTIONS YOU HAVE ATTENDED:
Name of College
Country
Name of College
State
Country
Bachelor's Degree
HIGHEST DEGREE EARNED:
High School or Equivalent
Associate Degree
ARE YOU TRANSFERRING FROM A UNIVERSITY IN THE UNITED STATES?
Yes
No
i
ATTACH
RECENT
PHOTO
HERE
(Required)
WHERE DO YOU WANT US
TO SEND THE I-20 FORM ?
HOME COUNTRY ADDRESS
U.S. ADDRESS
WILL PICK UP
COUNTRY OF BIRTH:
DATE OF BIRTH:
GENDER:
VISA ISSUE DATE:
VISA EXPIRATION DATE:
PASSPORT NUMBER:
APPLYING FOR ADMISSION TO:
Intensive English Program
PROGRAM OF STUDY (in college):
Fall Aug. Spring Jan. Summer May
If yes, please fill the following: TOEFL Test Date: TOEFL Score:
E-MAIL ADDRESS (Please print clearly)
HAVE YOU PREVIOUSLY APPLIED TO GADSDEN STATE COMMUNITY COLLEGE?
GADSDEN STATE COMMUNITY COLLEGE
INTERNATIONAL PROGRAMS
P.O. Box 227 - Gadsden, Alabama 35902-0227 (256) 549-8324 - Fax (256)549-8344
Yes,
No
WHEN:
MONTH DAY YEAR
MONTH DAY YEAR MONTH DAY YEAR
MONTH DAY YEAR
MONTH DAY YEAR
ARE YOU CURRENTLY IN THE U.S.A?
Yes
No
APPLICATION FOR ADMISSION
No
MONTH DAY YEAR
Master's Degree
Doctorate Degree
State
I understand that withholding information requested in this application, or giving false information may make me ineligible for admission to, or continuation in, the College. I agree to abide
by the rules, policies, and regulations of the College as outlined in the Student Handbook and College Catalog. With this in mind, I certify that all above statements are correct and complete.
APPLICANT'S SIGNATURE:
DATE:
YEAR
DAYMONTH
EDUCATIONAL RIGHTS AND PRIVACY ACT (''BUCKLEY AMENDMENT") NOTICE: Under the Federal Rights and Privacy Act 20 U.S.C. 12329 Gadsden State Community College may disclose certain
student information as directory information. Directory information includes the names, addresses, telephone numbers, dates of birth and major fields of study of students, as well as information about students
participation in officially recognized activities and sports, the weight and height: of members of athletic teams, the dates of attendance of students, degrees and awards received, and the most recent previous
educational agency of institution attended by a respective student. If any student has any objection to any of the aforementioned information being released about himself/herself during any given semester or
academic year, the student should notify in person or in writing the Registrar Room 124 of Allen Hall during the first three weeks of the respective semester or academic year.
HOW DID YOU HEAR ABOUT GSCC / ALI?
Family / Friend
GSCC Webpage
Online - other sites
Other
CITY OF BIRTH:
E-MAIL ADDRESS (Please print clearly)
College
APARTMENT #
NAME
Have your score sent directly from ETS to:
International Programs Office, GSCC, P.O. Box 227, Gadsden, AL 35902-0227
GSCC INSTITUTIONAL CODE 1262
/ /
/ /
/ /
/ /
/ /
/ /
/ /
SUBMIT COMPLETED FORM TO:
INTERNATIONAL PROGRAMS OFFICE, GSCC
P.O. Box 227, Gadsden, Alabama 35902-0227
.
International students or their sponsors must provide evidence of sufficient funds available to support financially two semesters of study at
Gadsden State Community College. This affidavit must be signed by the sponsor and stamped or sealed by a notary public, bank official or individual
authorized to certify documents. An
original
letter with an official signature on
bank letterhead
must also be submitted. The letter should verify
a current account balance and whether the account is in good standing. The sponsor must have a minimum income of $25,000 (U.S. dollars) per year.
Please Print
,
who resides at
I,
Name of Sponsor
Sponsor Address Sponsor Telephone Number
being duly sworn, depose and say that it is my intention to support
Name of Student
who resides at
Student Home Country Address
and comes to the United States to study at Gadsden State Community College
I
I am willing and able to maintain and support the prospective student. This affidavit is made by me for the purpose of
assuring Gadsden State Community College that the student I am sponsoring will have sufficient funds to cover tuition, fees and
living expenses during his/her course of study and will not become a public charge during his/her stay in the United States of America.
Relationship to student:
Mother
Father
Relative
Friend
Other
Company
Date
Signature of Sponsor
AFFIX STAMP OR SEAL
Signature and statement signed and sworn before me.
Signature of Notary Public, Bank Official
Address, Location
Date
AFFIDAVIT OF FINANCIAL SUPPORT
Student U.S. Address
I am aware that Gadsden State Community College does not consider students registered for classes unless the student pays
all
tuition and fees at registration.
$
Income per year
I certify that all information provided on this Affidavit of financial support is true and valid.
An original official bank letter verifying sponsor's financial account information must be attached. These documents will not be
returned
. We suggest that you request an additional copy to submit to the U.S. Embassy or Consulate with your visa application.
Employer or source of income and net amount received per year in U.S. dollars.
GADSDEN STATE COMMUNITY COLLEGE
INTERNATIONAL PROGRAMS
P.O. Box 227 - Gadsden, Alabama 35902-0227 (256) 549-8324 - Fax (256)549-8344
Student U.S. E-mail Address
Student Home Country E-mail Address
Sponsor Address
Sponsor E-mail Address
and reside at (U.S. address, if known)
Student U.S. Phone Number
ACCS Institution: __________________________________________
Complete and return to:
Medical History Form
This portion is to be completed by the student
Name
Last First Middle SS#/ID
Home Address
Street City State Zip
/ /
Cell Phone Date of Birth Male Female
Emergency Contact Phone Relationship
This medical data is necessary to serve as a baseline for medical clearance for actual enrollment. Details of abnormalities
should be recorded. Please check YES or NO to the following conditions.
CONDITIONS NO YES
Hypertension
Rheumatic fever or heart trouble
Liver trouble or jaundice (Hepatitis)
Asthma or tuberculosis
Major surgery or injury
Ulcers or gastroenteritis
Backache or joint trouble
Kidney trouble
Diabetes
Severe headaches
Epilepsy or convulsions
Dyspnea
Drug or alcohol problem
Has applicant been treated for any emotional disorders?
Has applicant, because of his/her health, withdrawn from college? If so explain
Does the applicant have any illness or medical condition that requires regular treatment?
Does the applicant miss school regularly or frequently due to any physical condition?
Has the applicant been hospitalized?
Any family member with chronic illness, mental or nervous disorders?
Anemia
Learning disability
Comments:
Present Health: Good Fair Poor Date of last exam: / /
ACCS Institution: __________________________________________
Complete and return to:
This portion is to be completed by a Physician.
Height Weight Skeletal Size: Small Medium Large EL
B/P Pulse Respiration Temperature
Laboratory Findings
Hemoglobin or Hematocrit WBC Serology
Urine: Sp.Gr Alb Sugar
EyesEars
Doyouwearglasses?NoYes Hearingnormal?NoYes
Doyouwearcontacts?NoYes Aredrumsintact?NoYes
DistantVision Withoutglasses R20/

Withglasses R20/
NearVision Withoutglasses R20/
Withglasses R20/
Head,NeckandFace Normal() Abnormal()
NoseandSinuses Normal() Abnormal()
MouthandThroat Normal() Abnormal()
Teeth Normal() Abnormal()
LungsandChest Normal() Abnormal()
Heart Normal() Abnormal()
VascularSystem Normal() Abnormal()
Abdomen Normal() Abnormal()
EndocrineSystem Normal() Abnormal()
Female:Breast Normal() Abnormal()
Female:Pelvic Normal() Abnormal()
Male:Genital Normal() Abnormal()
Male:Hernia Normal() Abnormal()
Present Health: Good Fair Poor Date of exam: / /
I certify that the above information is true.
Physician’sSignature Student’sSignature
TO BE COMPLETED BY COLLEGE OFFICIAL
Date Received: ___________________
Signature: _____________________________________
click to sign
signature
click to edit
ACCS Institution: __________________________________________
Complete and return to:
Immunization Form
To ensure the health and safety of our campus, immunizations against communicable disease is extremely
important. Vaccination against Measles, Mumps, Rubella (MMR), Tetanus, and Meningococcal is required, as
well as a negative Tuberculosis skin test. This is a requirement for all International Students. This form must be
completed and submitted prior to admission in any ACCS institution.
Name
Last First Middle SS#/ID
Address
Street City State Zip
Date of Birth / / Contact Number Email
Section A: Required Immunizations/Tests
Month/Day/Year Month/Day/Year
1. Meningitis Vaccine- within the last 5 years
(Menomune, Menactra, Menveo)
2. Measles, Mumps, Rubella
(MMR)
3. Tetanus
4. Tuberculosis Screening
TB Skin Test by PPD
Date Placed Date Read MM Neg Pos
Chest X-Ray
(if positive PPD or lab)
Date Result
Submit copy of chest X-ray report
SectionB:RecommendedImmunizations
Pleaseattachdocumentationofallchildhoodvaccinations(copyofBlueCard)
Month/Day/Year Month/Day/Year Month/Day/Year TiterDate&Result
TD
(Tetanus/Diphtheria)

Donotwritehere Donotwritehere Donotwritehere
AND/ORTdap
(Tetanus/Diphtheria)

Donotwritehere Donotwritehere Donotwritehere
Polio
Donotwritehere Donotwritehere
HepatitisB
Varicella
(Chickenpox)

Donotwritehere
I certify that the above dates and vaccinations are true.
SignatureofLicenseHealthCareProfessionalorAuthorizedIndividual Date
GADSDEN STATE COMMUNITY COLLEGE
INTERNATIONAL PROGRAMS
P.O. Box 227 - Gadsden, Alabama 35902-0227 (256) 549-8324 - Fax (256)549-8344
The Student and Exchange Visitors Information System (SEVIS) requires this office to have the following information in order to
process your
transfer or change of school to Gadsden State Community College.
Please complete the information in Section A and submit
this form to the International Student Advisor at your present or most recent school in the United States.
SECTION A - TO BE COMPLETED BY THE STUDENT
Family Name
First
Middle
Present Address
Institution Transferring From
Date of Attendance
I authorize my present International Student Advisor (or designated campus officer) to provide the information
below
Student Signature
Date
SECTION B - TO BE COMPLETED BY INTERNATIONAL STUDENT ADVISOR AT YOUR PRESENT
OR LAST ATTENDED SCHOOL IN THE U.S.
The above named student has applied for admission to Gadsden State Community College. Your assistance is appreciated
in completing this section below and returning this form with a copy of the student's current 1-20 and 1-94 to:
Gadsden State Community College
International Programs
Telephone: 256)549-8324
Fax Number: (256)549-8344
P.O. Box 227
Email Address: bduckett@gadsdenstate.edu
Gadsden, AL 35902-0227
1-94 Admission Number
Student Visa Type
I. Is this student currently IN STATUS with SEVIS?
If yes, please give release date
Yes If no, please explain:
No
2. Is this student currently applying for reinstatement?
Yes If yes, please provide date application was filed and copies of documents.
No
3. Is this student currently under practical training?
Yes If yes, please list all periods of authorized practical training (curricular or optional) if known.
No
4. Is he/she eligible to re-enroll at your institution?
Yes If no, please explain:
No
5. Has this student had any disciplinary/behavioral problems at your institution?
Yes If yes, please explain:
No
6. Has student encountered financial problems at your institution?
Yes If yes, please explain:
I certify that the preceding is to the best of my knowledge true and correct.
Date
Name and Title of Official
Signature
Name and Address of Institution
TRANSFER CLEARANCE
No
Phone Number
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Application International Nov 2019 Edit (Gadsden State Community College)

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