Fillable In The US Application5

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In The US Application5

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The In The US Application5 form is 2 pages long and contains:

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  • 20 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Butte College

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1
Butte College
Please type in your information, print, sign, and submit.
Applicant Information
Applicant Address
Language Proficiency
(Check all that apply)
English is my country’s primary/ official language.
I have completed one of the following Language Proficiency Tests. (Must submit proof of scores)
TOEFL IELTS EIKIN GTEC CBT
I have attended U.S. College/University, High School, or English Program. (Must submit letter of completion or transcript)
ALCI KAPLAN ELS
2+ years in US high School English U.S. College/ University Transfer Level English
NAME: ____________________________________________________________________________________________________________________________
LAST (FAMILY) FIRST: (GIVEN) MIDDLE
PREFERED NAME:________________________________ DATE OF BIRTH: _____________________
(Optional) (month/ day/ year)
COUNTRY OF BIRTH: __________
____________ COUNTRY OF CITIZENSHIP:_________________________________
PRIMARY LANGUAGE: ______________
_______ E-MAIL:____________________________________________________
(Check your e-mail regularly)
MAJOR: ____________________________________________ EDUCATIONAL GOALS: ______________________________________________
TERM APPLYING FOR: FALL 20 ______ SPRING 20 ______
HO
ME COUNTRY – PERMENANT ADDRESS
U.S. CURRENT ADDRESS (If available)
______________________________________________________
NUMBER & STREET
______________
________________________________________
CITY STATE POSTAL CODE
__________________________________________________
N
UMBER & STREET
______________________________________________________
CELL OR TE
LEPHONE NUMBER
_________________________________________________
CITY STATE/PROVINCE/PREFECTURE
_________________________________________________
COUNTRY POSTAL CODE
__________________________________________
CELL OR TELEPHONE NUMBER
For office use only
Student ID # ___________________
In The U.S Application ____________________________________
MALE FEMALE
UNKNOWN
/ OTHER
[Select One]
[Select One]
2
Butte College
How Did You Hear About Butte College? (Check all that apply)
A Friend or Family Member Your Own Research
Referred by Your Current School Butte Website
I Attended an Educational Fair: City ____________ Educational Agent/Advisor_______________________
Study in the USA Other:_________________________________________
Emergency Contact Information
Release of Information
Social Media (Optional)
Certification
I certify that all statements on this form are true and complete.
________________________________________ ________________________________
Applicant Signature Date (month/ day/ year)
With regard to matters pertaining to your health and personal safety, Butte College may need to release your information to an
outside agency, institution, or person. Please sign below to authorize the release of your information.
________________________________________ ________________________________
Applicant Signature Date (month/ day/ year)
We would like to connect with you through social media. You can either add us on Facebook or provide your social media so that we add you.
1) Our Facebook URL is https://www.facebook.com/dash.butte
2) If you want us to add you, then please provide one of the following:
a. Facebook URL_________________________________________________________
b. Instagram ____________________________________________________________
c. Other________________________________________________________________
DISCLAIMER: This will neither affect your admission nor be used to evaluate your application. It is another way to connect with you and share the
fun activities that the international students do during the semester.
the Welcome Center immediately.
Emergency Contact Person: _________________________________________________________________________
Address: _____
____________________________________________________________________________________
Home
Phone Number: _____________________________ Cell Phone Number: ____________________________
E-mail:__________________________________________ Relationship to Applicant: _______________________
Does t
his person speak English? Yes No
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In The US Application5

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Completed 3 March 2020

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