Information Form for Exchange Visitors
163 Stormont Street • New Concord • Ohio • 43762 • USA
Ph: +1-740-826-8127 Fax: +1-740-826-6113
Name: _________________________________________________________________________________
(Last/Family) (First/Given) (Middle)
Gender: Male Female Other
Date of Birth _________________________ Place of Birth ________________________________
(Month) (Day) (Year) (City/Country)
Country of Citizenship __________________ Country of Legal Residence ____________________
Permanent Address ______________________________________________________________________
Telephone ___________________________ E-mail address _______________________________
Who should be notified in case of an emergency during your period of study abroad?
Name __________________________________ Phone ( ) __________________________________
Address _______________________________________________________________________________
E-mail address __________________________________________________________________________
If you are a student in your country, please give the name and location of your school/college/university:
Current Student Status: 1
Year 2
Year 3
Year 4
Proposed dates of program in the United States: from ________________ to _______________________
Have you ever participated in a J-1 Exchange Visitor Program in the United States before? Yes No
If yes, please list the dates of your exchange program and the sponsoring agency/institution:
Financial Information: Who is funding your exchange program (flight, living expenses, etc.)? Please list stipends,
scholarships, and personal funds separately.
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Course Selection at Muskingum University
In order to help you register for the most appropriate courses while at Muskingum, please send transcripts with this
form. We need this information for advising purposes only.
Please find available courses on MuskieLink at
List below, in order of priority, six to eight courses that you would like to take. A normal course load would be 5 or
6 courses (15 to 18 credits). Please choose 2 or 3 alternates in case your first choices are already filled. Be sure that
you are looking at the correct term (e.g. Spring 20xx) and that you check for time conflicts. You will need to
consult the current University Course Catalog, which can be viewed at, for descriptions of the courses. Be certain to provide the
department abbreviation, course number, and section number (e.g. BUSI/341/3).
1. ______ ______ ______ 5. ______ ______ ______
2. ______ ______ ______ 6. ______ ______ ______
3. ______ ______ ______ 7. ______ ______ ______
4. ______ ______ ______ 8. ______ ______ ______
If you cannot find the courses you want, please describe your preferences below.
What is your current major field of study? __________________________________________________________
The student named above has presented all qualifications for study abroad that are required by
_______________________________________________ (home institution) and is certified for participation in the
Muskingum University exchange program.
Signature of Home Institution Representative _____________________________________________________
Representative’s Title _______________________________ E-mail ___________________________
Please stamp with institution’s seal:
Please indicate to whom and where and the student’s official transcript should be mailed:
Please return this form to:
Office of International Admission
163 Stormont St., Montgomery Hall 1A
New Concord, OH 43762 USA
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