International Student Questionnaire
In order to better assist us with the preparation of your I-20 and in support of your experience at Clackamas
Community College (CCC) as an International Student, please complete the following:
Full Name: __________________________________________________________________________________________
last (family name) first middle
Mailing Address: (if different than what has been provided on the application for admission)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Current Visa: _________________________________ Date issued: ____________ Date expires: _____________
Financial Sponsor’s name and relationship to student: __________________________________________________
_____________________________________________________________________________________________________
Native language: ______________________________ Other languages: ___________________________________
Please provide the following if you will be bringing a spouse or child with you to the United States that will
require the issuing of a F-2 visa:
Name: ______________________________________________________________________________________________
last first middle
Relationship: Spouse Child
Their date of birth: _____/_____/_____ Their country of birth: __________________________________________
Who may we contact in case of an emergency?
Name: ______________________________________________________________________________________________
Address: ______________________________________________________________ Phone:______________________
Relationship: ________________________________________________________________________________________
How did you learn about CCC? _______________________________________________________________________
Do you plan to earn a degree from CCC? Yes No
Intended program or major: __________________________________________________________________________
What are your plans for housing? _____________________________________________________________________
I understand that if I am accepted at Clackamas Community College I must complete a minimum of 12
credits each term (or 18 class hours each week if admitted to PIE) in order to remain “in status” with the
U.S. Department of Homeland Security (DHS). CCC also requires me to maintain a cumulative 2.0 grade
point average each term.
_______________________________________________________________________ ___________________________
Student Signature (required) Date
Please return to: international@clackamas.edu
Questions? Please contact international@clackamas.edu or +1-503-594-6074
08/22/17
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signature
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