1
International Student Program
Admission Application
STUDENT INFORMATION
Currently residing outside U.S. Currently residing in U.S. on a ______ Visa
Last (Surname/Primary) Name:
First (Given) Name: Middle Name(s):
Passport Name (in English letters):
Birthdate: (month) (day) (year)
Country of Birth:
Country of Citizenship:
Gender:
male female unknown/other Native Language(s):
Foreign (home country) Mailing Address:
Street Address:
City: _______________________________________________________ Province/Territory: _______________________________________________
Postal Code: ________________________________________________ Country: _________________________________________________________
Email Address:
Foreign Telephone (country code):
________________ (number): _____________________________________________________
U.S. Physical Address (if available):
Street Address:
City:
_______________________________________________________ State: ______________________________ Zip Code: ___________________
U.S. Telephone (if available): (area code): __________ (number): _________________________________________________________________
Which race do you consider yourself to be? (providing this information is voluntary)
q African American (872) q Alaska Native (015) q American Indian (597) q Chinese (605) q Filipino (608) q Japanese (611)
q Korean (612) q Native Hawaiian (653) q Vietnamese (619) q White (800) q Other Asian (621) q Other Pacific Islander (681)
q Other Race (specify) (799)_________
Are you of Spanish/Hispanic/ Latino ethnicity? (providing this information is voluntary)
q q
No
Yes, Mexican, Mexican American, Chicano (722) q Yes, Puerto Rican (727) q Yes, Cuban (709)
q Yes, other Spanish/Hispanic/Latino (722)
HEALTH INSURANCE
All international students MUST have current major health insurance by the first day of the quarter.
Will you have insurance from your country?
yes no
Will you need to purchase Washington State Colleges health insurance?
yes no
Passport Photo:
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EDUCATION
Name of last high school attended: ______________________________________________ City/Country: ________________________________
Once you begin college, will you have graduated from high school? q Yes ye, ar: _____ q No, highest grade level completed:_____
College/University (if applicable)
Previous college/university attended:
___________________________________________ City/Country: ________________________________
Did you graduate? q Yes, year: _____ q No, last year attended:_____
Previous college/university attended:
___________________________________________ City/Country: ________________________________
Did you graduate? q Yes, year: _____ q No, last year attended:_____
QUARTER YOU'D LIKE TO BEGIN ATTENDING CBC
Application deadlines: July 1 for Fall, October 1 for Winter, January 1 for Spring, March 1 for Summer.
When do you wish to begin? Year
Fall quarter Winter quarter Spring quarter Summer quarter
What will your intended college major be?
Eligible degree options listed on the International Student webpage under “Eligible Degree Options.”
TRANSFER STUDENTS (IF APPLICABLE):
Are you currently enrolled in a United States school?
No Yes, you must provide a CBC F-1 Transfer-In Form (available on website) from your current/previous school.
STUDENT ACKNOWLEGEMENT
In signing this form, I acknowledge that I have read and understand the attached instructions and that failure to submit
complete and accurate information and all required documents may result in denial of admission or dismissal from CBC.
Student Signature Date
ADMISSIONS REQUIREMENTS
Applicants MUST attach:
Official language proficiency scores (send directly to CBC, see website for accepted exams)
High school diploma (copy)
Official college/university transcripts
Submission Location:
Please submit the International Student Admissions Applications along with the additional documents listed. Incomplete applications
will not be reviewed until all documents have been received.
Completed applications can be submitted in person or by mail to the following address.
International Student Program
Columbia Basin College
2600 North 20th Ave., MS-H4
Pasco, WA 99301-3379
USA
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International Student Program
Certificate of Financial Responsibility
All international students are required by the U.S. Department of Homeland Security (DHS) to prove that they have adequate funds to pay for
educational and living expenses during their stay in the U.S before a
Certificate of Eligibility (I-20) can be issued.
In addition to completing the information requested in this form, provide official bank statements no more than six months old, showing that
funds are available in U.S. dollars.
APPROXIMATE COSTS
Quarterly Tuition/Fees:
$3,500.00 (per quarter)
Books: $400.00 (quarterly average)
*Living Expenses: $16,000.00 (Annually)
*Determined by student’s lifestyle
STUDENT INFORMATION:
Last (Surname/Primary) Name:
First (Given) Name: Middle Name(s):
Official Certification of Sources of Funds and Amounts (Please use U.S. Dollars)
Sources of Funds (check all that apply)
Assured Support
(enter amount for each
source in U.S. dollars)
q Self-Support
Please attach a bank statement* verifying the amount you indicate.
$
q Parents or Individual Sponsors
Please attach a bank statement* verifying the amount you indicate.
$
q Your Government or Other Sponsoring Agency
Please attach a signed copy of your letter of award specifying the current date, the dollar
amount (in U.S. dollars), and the exact starting date and length of the funding.
$
q Other (please specify): ________________________________________
Please attach a bank statement* verifying the amount you indicate.
$
TOTAL First Year’s Funds
(Total Needs To Equal Approximate Costs)
$
*All financial documents must be in English and must have a signature, official seal, or be on letterhead from an official agency.
Documents must be no more than six months old.
Dependents
Are you requesting any dependents accompany you?
q No q Yes (If you intend to bring dependents with you, you must complete the table below)
Relationship
First (Given) Name
Birthdate
(MM/DD/YYYY)
Country of Birth
Country of Citizenship
Gender
Total Costs of Dependents $___________________________ (add $6,300 per year for spouse and $5,130 per year for each child)
I certify that the information is true, correct, and complete, and that I have adequate funds available to complete my full
course of study at this institution. I understand that the costs listed above are estimates and are subject to change without
notice. I understand that any misrepresentation may be cause for refusing/revoking admission and/or my Visa.
Student Signature Date
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International Student Program
Affidavit of Support
Required ONLY
if your financial sponsor is a U.S. citizen paying all or part of the living expenses listed on the Certificate of
Financial Responsibility or providing room and board.
I, residing at
(Financial Sponsor Name) (Street Address)
(City) (State) (Zip Code)
BEING DULY SWORN DEPOSE AND SAY:
1.
I was born on at
(Date) (City) (Country)
If you are not a native born United States citizen, answer the following as appropriate:
a.
If a United States citizen through naturalization, give certificate of naturalization number
b.
If a United States citizen through parent(s) or marriage, give citizenship certificate number
c.
If a United States citizenship was derived by some other method, attach a statement of explanation.
d.
If a lawfully admitted permanent resident of the United States, give “A” number
2.
That I am years of age and have resided in the United States since (date)
3.
That this affidavit is executed on behalf of the following international student:
International Student Name
Gender
Age
Citizen of (Country)
Marital Status
Relationship to Sponsor
Presently resides at Street Address
City
State/Province/Territory
Country
Name of spouse and children accompanying or following to join person:
Spouse
Sex
Age
Child
Sex
Age
Child
Sex
Age
Child
Sex
Age
Child
Sex
Age
Child
Sex
Age
4.
That this affidavit is made by me for the purpose of assuring the United States Government that the person(s) named in item 3 will not become a public
charge in the United States.
5.
That I am willing and able to receive, maintain and support the person(s) name in item 3. That I am ready and willing to deposit a bond, if necessary, to
guarantee that such person(s) will not become a public charge during his or her stay in the United States, or to guarantee that the above named will maintain
his or her nonimmigration status if admitted temporarily and will depart prior to the expiration of his or her authorized stay in the United States.
6.
That I understand this affidavit will be binding upon me for a period of three (3) years after entry of the person(s) named in item 3 and that the information
and documentation provided by me may be made available to the Secretary of Health and Human Services and the Secretary of Agriculture, who may make it
available to a public assistance agency.
7.
That I am employed as, or engaged in the business of with
(Type of Business) (Name of concern)
at
(Street Address) (City) (State) (Zip Code)
I derive an annual income of (if self-employed, I have attached a copy of my last income tax return or report of commercial
rating concern) which I certify to be true and correct to the best of my knowledge and belief ............................................................. $
The balance of all my savings and checking accounts in the United States is ..................................................................................... $
I have other personal property, the reasonable value of which is ............................................................................................................... $
I have stocks and bonds with the following market value, as indicated on the attached list, which I certify to be true and
correct to the best of my knowledge and belief ................................................................................................................................... $
I have life insurance in the sum of ................................................................................................................................................................ $
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With a cash surrender value of ..................................................................................................................................................................... $
I own real estate valued at ............................................................................................................................................................................ $
With mortgages or other encumbrances thereon amounting to ................................................................................................................. $
Which is loca et d at
(Street Address) (City) (State) (Zip Code)
8.
That the following persons are dependent upon me for support:
(Place an “X” in the appropriate column to indicate whether the person named is wholly or partially dependent upon you for support.)
Name of person
Status
Age
Relationship to me
Wholly Dependent
Partially Dependent
Wholly Dependent
Partially Dependent
Wholly Dependent
Partially Dependent
9.
That I have previously submitted affidavit(s) of support for the following person(s). If none, state “None.”
Name Date Submitted
Name Date Submitted
10.
That I have submitted visa petition(s) to the Immigration and Naturalization Service on behalf of the following person(s). If none, state “None.”
Name Date Submitted
Name Date Submitted
OATH OR AFFIRMATION OF SPONSOR
Sponsor and Beneficiary Liability
Under section 213 of the Act, if the person you are sponsoring becomes a public charge, the agency that provides assistance may be able to sue you to recover
the cost of the assistance.
In addition to that provision, your income and assets may be combined with the income and assets of the person you are sponsoring in determining whether that
person is eligible for Food Stamps, 7 U.S.C. 2014(i)(1), Supplemental Security Income (SSI), 42 U.S.C. 1382j, and Temporary Assistance for Needy Families (TANF), 42
U.S.C. 608.
I acknowledge I have read the Sponsor and Alien Liability above and am aware of my responsibilities as an immigrant sponsor under the Social Security Act, as
amended, and the Food Stamp Act, as amended.
I swear (affirm) that I know the contents of this affidavit signed by me and the statements are true and correct.
Signature of Sp
onsor
Subscribed and sworn to (affirmed) before me this day of , Year at .
My commission expires on
Signature of Officer Administering Oath
Title
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights,
Title IX, equal opportunity and affirmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic origin,
parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information,
honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or
service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment.
Questions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at
(509) 542-5548.Individuals with disabilities are encouraged to participate in all college sponsored events and programs. If you have a disability,
and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or
1-800-833-6384. This notice is available in alternative media by request.
Notary Seal
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