8/2011
FORM B
INTERNATIONAL STUDENT
FINANCIAL CERTIFICATE
NOTE: ALL INFORMATION SHOULD BE TYPED OR PRINTED
Please Note: The admissions process is not complete until this form has been submitted with the requested certification. VISA
documents are issued only when all admissions procedures have been satisfied.
Please print or type
1. Name: _______________________________________________________________________________________
Last First Middle
2. Address: ______________________________________________________________________________________
3. I am applying for admissions to Halifax Community College beginning Fall Semester 20____________.
4.
Check all boxes that apply:□
□ I expect my program of study to require _____ years of study.
I expect to remain in Halifax during the summer periods.
□ I expect to attend summer school sessions.
For items 5, 6 7, 8 and 9, list dollar amounts under 1
st
and 2
nd
year when applicable.
5. Personal and/or family savings
Name of Bank:
1
st
Year
2
nd
Year
Note: A bank official’s signature is required on the certification below if the student is supported in part or whole
by personal funds. A statement showing current bank balance should be attached.
6. Note: Signature of parent/sponsor required below. Supply bank certification as stated above.
Parent(s)/Sponsor(s)
1
st
Year
2
nd
Year
7. Your Government
1
st
Year
2
nd
Year
Note: Enclose a signed copy of your award.
8. University award is from
Name:
1
st
Year
2
nd
Year
Amount:
9. Other: Please specify
1
st
Year
2
nd
Year
Note: Enclose a signed affidavit from authorized person to certify accuracy.
Each of the column totals should equal the estimated academic year total.
TOTAL
TOTAL
You should expect to have when you arrive at Halifax Community College sufficient funds to cover books, room
and board, supplies and personal expenses for at least one academic year (approximately $14,110.00).
c:\users\caharris\desktop\form b-financial certificate.doc
8/2011
OFFICIAL CERTIFICATION OF SOURCES OF FUNDS AND AMOUNTS
This is to certify that I have read the information furnished by the applicant on this form, that it is true and accurate, and that the funds
are available and will be provided as specified. (Attach current bank statement.)
10.
Bank Official’s Signature and Seal:
Bank Official’s Name (Printed):
Name of Bank:
Address:
Date:
This is to certify that I have read the information by the applicant on this form, that it is true and accurate, and that the funds are
available and will be provided as specified. (Attach current bank statement.)
11.
Parent/Sponsor’s Signature:
Parent/Sponsor Name: (Printed):
Relationship to Applicant:
Address:
Date:
12. I, ____________________________, (applicant’s name) certify that the total amount of money that I have available for my first
academic year of study at Fayetteville Technical Community College is $ __________, and that the total amount available for each
subsequent year of study is $ ____________. I also certify that I will buy adequate health hospitalization insurance. I further certify that
the above information provided is correct and complete and that I shall not require additional financial assistance.
13. I am applying for entry into the following curriculum: __________________________________________________
14. Describe your significant work experiences (responsibilities, positions held, type of business, ministry, teaching, etc.).
15. Describe your career objectives. What do you plan to do with your education?
Applicant’s Signature: ___________________________________________ Date: ______________________
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