INTERNATIONAL EDUCATION ADMISSIONS FORM
International Education Programs
4500 Steilacoom Blvd. S.W. Please tell us how you learned about Clover Park Technical College:
Lakewood, WA 98499 USA A friend or agent Advertisement Internet
Tel: 253.589.6089 Fax: 253.589.6056 Education Fair CPTC Student, Instructor or Staff
International@cptc.edu; www.CPTC.edu/internationals Other ___________________________________________
TYPE OR PRINT USING BLOCK LETTERS
FAMILY NAME AS PRINTED ON PASSPORT
FIRST NAME MIDDLE
PREVIOUS LAST NAME
FEMALE MALE
DATE OF BIRTH _________________________________
MOTHER’S NAME
FATHER’S NAME
COUNTRY OF BIRTH:
___________________________________________________
CITIZENSHIP: _______________________________________
NATIVE LANGUAGE: _________________________________
WHAT QUARTER DO YOU PLAN TO
BEGIN?
SUMMER / JUNE-July
FALL / SEPTEMBER
WINTER / JANUARY
SPRING / MARCH-APRIL
PROGRAM YOU WISH TO ENTER AT CPTC:
____________________________________________________
2
ND
OPTION _________________________________________
DO YOU PLAN TO TRANSFER TO A FOUR-YEAR COLLEGE
OR UNIVERSITY AFTER ATTENDING CPTC?
YES NO
IF CURRENTLY IN THE U.S., WHAT IS YOUR
VISA CLASSIFICATION:
F-1 M-1 OTHER___________
VISA # _____________________________________________
PASSPORT WITH I-94 REQUIRED
EXPIRATION DATE: _________________________________
EDUCATION:
NAME OF HIGH SCHOOL:
__________________________________________________
COUNTRY: ________________________________________
DATES ATTENDED;__________________________________
GRADUATED? YES NO
EDUCATION:
MOST RECENT COLLEGE/UNIVERSITY:
____________________________________________________
COUNTRY: __________________________________________
DATES ATTENDED:___________________________________
GRADUATED? YES NO
PERMANENT ADDRESS IN HOME COUNTRY STREET ____________________________________________________________________________________________________
PROVINCE / /CITY / /COUNTY ________________________________________________________________ COUNTRY ____________________________________________
PERMANENT EMAIL: ____________________________________________________________________ PERMANENT PHONE: ____________________________________
YOUR ADDRESS IN U.S. STREET _____________________________________________________________________________________ APT# ________________________________
CITY ________________________________________________ STATE ___________________________________ ZIP CODE ___________________________________
YOUR EMAIL: ____________________________________________________________________________ PHONE: _______________________________________________
EMERGENCY CONTACTS: NAME: ____________________________________________________________________________ PHONE: __________________________________
EMAIL: __________________________________________________________________________________ RELATIONSHIP: _________________________________________
IMPORTANT INFORMATION;
1. All students are required to pay all tuition and fees before the start of class. Financial aid is not available for international students.
2. International students must be covered by health and accident insurance. Verification of insurance is required. Clover Park Technical
College is not liable for failure to comply with this requirement.
3. International students must provide the International Education Office with a current address and telephone number.
4. International students must maintain satisfactory progress at all times or face possible probation or withdrawal from the college.
5. International students must maintain current VISA status and comply with all regulations regarding their VISA status or face possible
withdrawal from the college.
I UNDERSTAND THE ABOVE REQUIREMENTS AND DECLARE THAT THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE.
_____________________________________________________________ ____________________________________________________________________ __________________________
NAME – PRINT IN BLOCK LETTERS SIGNATURE DAT
