Fillable GLOBAL CONNECTIONS APPLICATION

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GLOBAL CONNECTIONS APPLICATION

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Country of origin: US
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GLOBAL CONNECTIONS APPLICATION
FALL/SPRING | Side A (both sides must be completed)
Full Name _________________________________________________________________________________________________________________________
Family/Last Name(s) Given Name/First Name(s)
I plan to attend Tompkins Cortland Community College q Fall ___________ q Spring ___________
Student ID# __________________________________________________ Email address _______________________________________________________
Date of Birth (month/day/year) ______________________ q Male q Female
Country of Birth ______________________________________________________ Country of Citizenship ___________________________________
Are you a U.S. citizen/permanent resident? q Yes q No
If a permanent resident, please provide your green card. If a U.S. citizen please provide your U.S. Passport and social security card.
If no, what type of non-immigrant visa will you be studying under? q FI q Other List Category (J-1, H-2B, etc)
If other, please explain___________________________________________________________
***YOU MUST PROVIDE A COPY OF THE IDENTIFICATION PAGE OF YOUR PASSPORT***
Permanent Address - Home Country
FOR OFFICE USE ONLY___________________________
POPULATION CODE
PLEASE COMPLETE BACK
PERSONAL DATA (exactly as stated on your passport) Please PRINT legibly or TYPE.
Address 1 ______________________________________________________________________________________________________________________
Address 2 ______________________________________________________________________________________________________________________
City _______________________________________________________ Province/Territory__________________________________________________
Postal Code_____________________ Country_______________________________________ Phone Number________________________________
Emergency Contact #1 _____________________________________________________________ Relationship to student_______________________
Phone_____________________________________________________________________________ Email _______________________________________
Emergency Contact #2 _____________________________________________________________ Relationship to student_______________________
Phone_____________________________________________________________________________ Email _______________________________________
Correspondence from Tompkins Cortland Community College should be directed to: q Mailing Address q Permanent Address
Emergency Contacts (Two emergency contacts must be provided)
Program/Degree Selection*
q Applied Science and Technology A.A.S
(Pending Fall 17)
q Business Administration A.A.S.
q Construction and Environmental
Technology A.A.S.
q Computer Information Systems A.A.S.
q Digital Media Production A.A.S.
(Pending Fall 17)
q Entrepreneurship A.A.S.
q Hotel and Restaurant Management A.A.S.
q International Business A.S.
Other**____________________________________
**(Availability will require cohort)
* Please note: Program availability
depends on student enrollment each
summer. Some programs listed may
not be available each summer.
Name _____________________________________________________________________________________________________________________________
Family/Last Name(s) Given Name/First Name(s)
Student ID# __________________________________________________________________________________________________________________
EDUCATIONAL DATA
Write the type of school you attended such as colegio, ecole secondaire, gymnasium, instituto, university, etc., using terminology of
the educational system.
Write the name of examinations passed, or of certificates, diplomas, or degrees earned, such as Certificate of Education (ordinary
or advanced), Bachillerato, Abitur, Maturita, Baccalaureate, Studentereksmen, etc., using the terminology of the educational system.
SECONDARY EDUCATION (HIGH SCHOOL) INFORMATION
School Name _____________________________________________________________________________________________________________________
Date of Graduation (Diploma received) ______________________________________________________________________________________________
Primary Language of Instruction ____________________________________________________________________________________________________
Submitting a copy of your high school transcript is required for admission to Tompkins Cortland Community College.
If second summer student, this is not required.
HIGHER EDUCATION INFORMATION
Home University____________________________________________________________________________________________________________________
Career/Degree Program ___________________________________________________________________________________________________________
Dates Attended (month/year to month/year) __________________________________________________________________________________________
Certificate/Diplomas/Degrees received _______________________________________________________________________________________________
Primary Language of Instruction ____________________________________________________________________________________________________
All candidates are required to submit official transcripts from all schools, universities, and colleges attended.
CERTIFICATION
I certify that all information on this form is true to the best of my knowledge.
Applicant’s Signature:_______________________________________________________________________ Date: ____________________________
I, _________________________________________________________________________ , authorize Tompkins Cortland Community College the
unlimited usage of photographs/videos taken of me and the personal information disclosed below for advertising and promotion for the
College in any media form.
I understand that Tompkins Cortland Community College retains all rights and responsibilities of ownership and copyright for this material.
Signed ___________________________________________________________________________ Date______________________
FALL/SPRING | Side B (both sides must be completed)
BOTH SIDES MUST BE COMPLETED
FOR OFFICE USE ONLY___________________________
POPULATION CODE
PHOTO/VIDEO RELEASE
GLOBAL CONNECTIONS APPLICATION
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P.O. Box 139, 170 North Street Dryden, NY 13053-0139
INTERNATIONAL STUDENT AFFIDAVIT OF SUPPORT
Individual Student or Sponsor’s Official Certification of Available Funds and Intention of Support
__________________________________________ _________________________________________
Name of Student Student ID Number
_______________________________________________________________________________________
Name of Sponsor (If more than one, each sponsor should submit a separate affidavit)
_______________________________________________________________________________________
Sponsor Address
_______________________________________________________________________________________
Sponsor E-Mail Sponsor Phone Number
My signature below certifies that it is my intention to fully support the educational and living expenses of
the student named above for the duration of his or her studies.
__________________________________________ ________________________________________
Signature Printed Name
Estimated Cost of Attendance per 9 month Academic Year (Summer Not Included)
Tuition – with Be One of US Scholarship (Living on Campus) $5,100
Non-Resident/International Fee (for students receiving the Be One of US Scholarship: $1,000
Tuition – without Be One of US Scholarship (Living off Campus) $10,500
Other Fees: $1290
Books/Supplies $1,200
Room (on Campus, reduced rate if reserved by set deadline July 1/Fall December 1/Spring)* $7,400
Room (on campus, reservation deadline not met)*
*Housing during breaks is available for an additional cost but is not included in estimate. $8,400
Meals (Campus meal plan – required if living on campus OR off-campus meals) $2,900
Required health insurance: $1,500
Totals:
Living On Campus, Be One of US Scholarsip, housing deadline met: $20,390
Living Off-Campus, no Be One of US Scholarship $24,790
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GLOBAL CONNECTIONS APPLICATION

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Completed 21 September 2020

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