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 Oce 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 oer any housing. Students are responsible to arrange for their
own housing.
Local Living Arrangements: What are your plans for local living arrangements?
________________________________________________________________________________
________________________________________________________________________________
International Student Oce | 100 Elliott Street | Haverhill, MA 01830 | Phone: 978-556-3726
Fax: 978-738-7450 | Email: international@necc.mass.edu
