International Student Application
International Student Program (SSA113)
1111 Figueroa Place
Wilmington, CA 90744-2397 U.S.A.
Office: (310) 233-4111 FAX: (310) 233-4291
Please fill out this application completely. You may either type or print clearly. After you have collected all your application materials, mail your packet to
the address above or hand carry the documents to our office. These documents will not be returned to you once they are submitted to the college. Please
contact us if you have any questions and we will be happy to assist you.
Semester you will first attend: Spring Fall Year: 2017 2018 2019 2020 2021
Social Security Number (if any): Gender: Male Female
Last Name (surname): First Name:
Middle Name: Date of Birth:
Country of Birth: Country of Citizenship
Foreign Address: City:
State or Province: Country: Postal Code:
USA Address (if any):
City: State: Zip Code:
Home Phone Number: Cellular Phone Number:
E-Mail Address:
High School: Year Graduated:
College or University: Year Graduated:
Please consult the LAHC On-line College Catalog before you answer the following two questions:
1. Level of Education you will pursue in the United States: Certificate of Achievement Associate of Arts or Science (AA or AS)
2. My major will be (must be a valid LAHC major):
Please mark your answer to the following questions (do not leave anything blank):
1. Did you take the TOEFL, IELTS, Step Eiken Test within the last two years? Yes, my score was: Date:
2. I am applying as (check one only):
A new student from a country outside the United States
An F-1 visa transfer student currently studying in the United States (specify current school):
A change of status student from within the United States (please specify your current visa status B-2, F-2, H-1B):
Other (please specify):
3. Do you have any F-2 Visa Dependents? Yes No
If yes, please list the name of each dependent:
Upon registering for classes at LAHC, I will be enrolled in full-coverage health insurance through Ascension Benefit & Insurance Solutions - Students Insurance
(Anthem - Blue Cross). The cost of coverage per semester is $638.00 USD. This cost will be included in my tuition bill every Fall and Spring Semester.
MANDATORY - NO EXCEPTIONS: Must check and initial: Yes, I understand the health insurance requirement for
LAHC. I agree to pay for district mandated medical insurance through LAHC College each semester even if I have my own
medical insurance coverage.
By completing this application, you are agreeing to follow all conditions of enrollment at LAHC. You are responsible for the
accuracy and truth of all statements made here:
Signature: Date:
If you have any questions regarding this application, please e-mail us at: or call (310) 233-4111
SSA 115
click to sign
click to edit