International Student Data Form
This form must be completed by all international students applying for SEVIS Form I-20. Please answer all
the questions completely and return the form with the requested nancial documentation and copy of U.S.
immigration documents (if applicable). Once the record has been reviewed and determined to be complete,
the International Student Oce will forward immigration documents to you with instructions on how to
apply for a student visa at the nearest U.S. Embassy or Consulate.
2 01905-044
General Information (Please enter all names exactly as they appear on your passport)
N am e____________________________________________________________________________________ M al e Fe mal e
Last First Middle
Date of Birth __________________________________ Place of Birth ______________________________________________________ __
MM/DD/YYYY City/Country
Country of Citizenship ________________________________ Country of Legal Residence __________________________________
Permanent Address in Home Country
Stre et ___________________________________________________________ Cit y________________________________________________
St ate/ Provin ce_______________________________ Cou ntr y__________________________________ Pos tal Co de _________________
Email ___________________________________________________________ Ph on e ______________________________________________
Student U.S. Address
Stre et ___________________________________________________________ Cit y________________________________________________
State___________________________________________________________________________________ Zip Code____________________
Local Person (in the U.S.) to Notify in Case of Emergency
N am e____________________________________________________________________________________ Phone _____________________
Last First
Stre et ___________________________________________________________ Cit y________________________________________________
State___________________________________________________________________________________ Zip Code____________________
Northern Essex Community College DOES NOT oer any housing. Students are responsible to arrange for their
own housing.
Local Living Arrangements: What are your plans for local living arrangements?
________________________________________________________________________________
________________________________________________________________________________
International Student Oce | 100 Elliott Street | Haverhill, MA 01830 | Phone: 978-556-3726
Fax: 978-738-7450 | Email: international@necc.mass.edu