After submitting this form to your home University Coordinator,
you may also contact Erin Beecher, CCSU Study Abroad Advisor, Center for International Education
Central Connecticut State University, 1615 Stanley St. Henry Barnard-Room 123, New Britain, CT, 06050, USA
(860) 832-2043, ebeecher@ccsu.edu
Incoming International Exchange Student Application
Central Connecticut State University
Application Instructions:
Students enrolled at institutions that have exchange partnerships with Central Connecticut State University (CCSU) should
submit this form – together with with the following documents -- to their Home University Coordinator
∙ Photocopy of Passport ∙ Transcript(s) from your Home University
∙ Affidavit of Support ∙ International Medical Packet
∙ Course Selection Form (see caveat below) ∙ On-Campus Housing Application
The required documents can be found on the CCSU website at: http://www.ccsu.edu/page.cfm?p=4341
. Note: The Course
Selection Form should be NOT be submitted until courses are posted on the CCSU website; forms submitted before then
cannot be considered.
Application Deadlines:
Fall Semester and Full year exchange-April1; Spring Semester-October15
Applicant Information:
Name: (exactly as printed on your passport):
________________________________________________ _________________________________________________ __________________________________________
Family/Last name Given/First Name Middle name
Home University:_____________________________________________ Level of Study (check one): ____Undergraduate ____Graduate
Academic Major/Primary
Field of Study:___________________________________________ Area of Study_______________________________________
Duration of Study: Fall 20____ Spring 20____ Academic Year 20____ Gender: _______ Male _______ Female
Current Mailing Address: ___________________________________________________________________________________________________________________
Street Address
_________________________________________________________________ _____________________________________________________ _______________________________
City/Town Country Postal Code
E-Mail Address: _________________________________________________________Phone/Cell Number: _____________________________________________
Passport Number: ______________________________________________________ Date of Birth: (month/day/year) ________________________________
City of Birth: __________________________________________________ Country of Birth: ___________________________________________________________
Country of Citizenship: _______________________________________ Country of Legal Residence: ______________________________________________
Emergency Contact Information:
Name: ____________________________________________________________________Relationship:____________________________________________________
Phone/Cell Number:
_______________________________ E-Mail:____________________________________________________________
Race/Ethnicity (This information is for statistical purposes only and is optional):
Are you Hispanic/Latino (check one): ___Yes ___No. What is your racial background (check one or more)? ___White; __ American Indian or Alaska
Native; ___Black or African American; ___ Asian; ___White Native Hawaiian or Other Pacific Islander
Signature: ____________________________________________________________________ Date: ___________________________________________
click to sign
signature
click to edit
![]()
