Fillable NSE Application (Wichita State University)

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NSE Application (Wichita State University)

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NSE Application – page 1 of 4
Prior to completing this application:
Review wichita.edu/nse and “How it Works” on nse.org
Return This Form To:
Trish Gandu, trish.gandu@wichita.edu
NSE Coordinator
Cohen Honors College
Wichita State University
Shocker Hall, Building A
Wichita, KS 67260-0102 Fields surrounded by red are required.
Contact Information
Name: First ________________________________ Middle _________________ Last __________________________
Current Address:
Street/Residence Hall and Room ________________________________________________________________
City, State/Province, and Zip/Postal Code _________________________________________________________
Permanent Address:
Street ______________________________________________________________________________________
City, State/Province, and Zip/Postal Code _________________________________________________________
Cell Phone _____________________ Home Phone ____________________
Emergency Phone_______________________________
Campus E-mail ________________________________ Preferred/Personal E-mail __________________________________
myWSU ID ___________________________ High School ______________________________________
High School Graduation Year _____________ Any Previous College ______________________________
Demographic Information
Date of Birth (MM/DD/YYYY): ________________________ Gender: Female Male Other
Are you currently living in on-campus housing? Yes No
Are you a resident of the state/province in which your home campus is located? Yes No
Country of Citizenship: United States Canada Other ________________________________________
Non-resident alien — If non-resident alien, visa type_______________ Lawful permanent resident
Application Deadline: February 1 by 5 p.m.
Office Use Only
DATES RECD: App ________ App Fee ________
Program of Study ________ Ref #1 ________ Ref #2 ________
(The application is not complete – and no placement request will be submitted – until the fee has been
paid. Should you not be placed, be placed and decline your placement, accept your placement and later
withdraw or become ineligible, no refund will be given.)
CIP (Classification of Instructional Programs) Code: ____________
Credential Level: __________ Program Length: _______________
Application for Exchange
NSE Application – page 2 of 4
Demographic Information, continued
Ethnicity (Optional): If you wish to be identified with a particular ethnic group, please select the choice that most accurately
describes your heritage. No information you provide will be used in a discriminatory manner.
Are you of Hispanic or Latino descent? Yes No
Please check one or more of the following groups if any describe you.
American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White Two or more races, not Hispanic or Latino Other
Primary reason(s) for exchange – check all applicable
access different courses/faculty enter host campus honors program
evaluate graduate schools exchange as a resident assistant
live in a different area language study
personal growth look for future employment
participate in host campus international program other: _______________________________
Scholastic and Other Information
Current Class Level: Fr So Jr Sr Class Level While on Exchange: So Jr Sr
Cumulative grade point average: ____________ (4.0 scale)
Major: ________________________________ Minor: _______________________________
Will you need courses in your major while on exchange? Yes No
Are you currently receiving financial aid? Yes No
Are you currently receiving VA educational benefits? Yes No
Are you currently enrolled in the honors program? Yes No
In what languages are you fluent (check all applicable)? English French Spanish Other ______________________
Where do you plan to reside at the exchange school? Residence hall Sorority/Fraternity Off-campus
Marital Status: Single Married
Will you be accompanied on exchange by: spouse Yes No children Yes No
Do you wish to go on exchange with another student(s): No Yes: student’s name______________________________________
Name of campus at which the student is enrolled: ________________________________________________
Exchange Requests
Period of requested exchange: Fall Semester 20____ Spring Semester 20___
(Mark all that apply) Fall Quarter 20___ Winter Quarter 20____ Spring Quarter 20_____
Summer 20____
List by preference the institutions you wish to attend:
Name of Institution Semester/Quarter My major offered Need campus housing
1. ___ S ___Q ___ Yes ___ No ___ Yes ___ No
2. ___ S ___Q ___ Yes ___ No ___ Yes ___ No
3. ___ S ___Q ___ Yes ___ No ___ Yes ___ No
4. ___ S ___ Q ___ Yes ___ No ___ Yes ___ No
5. ___ S ___ Q ___ Yes ___ No ___ Yes ___ No
Educational Background
Number of credits completed to date: _________ Number of credits enrolled in current term: _____________
Expected graduation date: __________________
Do you have any incomplete grades, missing grades or other deficiencies (e.g. failure to complete required
proficiency tests)? Yes No
If yes, please explain: __________________________________________________________________________________
Activities, positions, honors while in college: _______________________________________________________________________
___________________________________________________________________________________________________________
NSE Application – page 3 of 4
Special Needs or Circumstances
If you have a physical condition for which accessible, on-campus housing or classroom accommodation might be needed; a
documented disability which may require academic accommodation (e.g., notetakers, taped texts); a medical condition which might
require immediate attention during exchange; or a condition which might affect emotional or mental well-being during exchange,
you are encouraged to identify your needs by attaching a separate page indicating the nature and extent of your circumstances and
arrangements which are currently being made for you on this campus. Also indicate whether or not we may contact your requested
host campuses at this time.
NSE does not discriminate on the basis of special needs. Rather, your disclosure at this stage of the application process is invited in
order to assist you in identifying a placement site which can provide reasonable accommodation of your needs. Following
placement, it is your responsibility to consult the host campus coordinator and ADA officer to determine the deadlines by which you
must submit written, current, and professionally documented information as required by your host campus. Written documentation
is usually due to the host campus two to three months prior to enrollment.
Other Considerations
Have you ever been convicted of a felony? Yes No
Are you on probation, parole, or have any legal judgments pending against you either inside or outside campus?
No Yes If yes, please explain: _________________________________________________________________
Are you currently under any campus disciplinary action for violation of codes of academic or student conduct?
No Yes If yes, please explain: _________________________________________________________________
Do you have any outstanding indebtedness to the campus (tuition, fees, room, meals, library or parking fines)?
No Yes If yes, please explain: _________________________________________________________________
Language Proficiency
What is your native language? English French Spanish Other: ___________________________________
If you plan to exchange to a campus in Puerto Rico, you must be certified for proficiency in Spanish. If you plan to exchange to a
French-speaking university in Canada, you must be certified for proficiency in French. If English is not your first language, for all
other NSE locations you must demonstrate proficiency in English. Language proficiency must be determined prior to placement.
Recommendations/References
List the individuals who are writing references for you. Submit reference forms to your advisor and one other person who will
recommend you for exchange.
Advisor Department/Office Phone E-mail
Name Relation/Department/Office Phone E-mail
Emergency Contact
Name _________________________________________________ Relationship ________________________________
Street _____________________________________________________________________________________________
City, State/Province, and Zip/Postal Code ________________________________________________________________
Land-line Phone ______/___________ Cell Phone______/___________ E-mail __________________________
Release of Information
The collection, retention, and dissemination of your records and information about you are subject to federal regulation under the
Family Education Rights and Privacy Act (FERPA) of 1974. You are responsible for specifying the persons or agents who have access
to your records. Therefore, it is necessary that we obtain your permission to request and release information pertinent to your
exchange. Please read the following statements and sign below:
I understand that it will be necessary for my campus to obtain certain information about my academic and non-academic record
in order to: 1) ascertain my eligibility and suitability for an exchange through NSE, and 2) facilitate my exchange after it is
arranged. I hereby grant permission to the NSE coordinator and/or designee to obtain information that is appropriate to my
NSE Application – page 4 of 4
application and participation in the exchange including, but not limited to, letters of recommendation, permanent academic
records and transcripts, conduct, fiscal records, medical records, all for the purposes of exchange placement and participation,
continuation, or termination.
I give permission to the NSE coordinator and/or designee to contact appropriate personnel in order to verify that I am under no
disciplinary action for violation of codes of academic and student conduct, I do not have any outstanding indebtedness to the
campus, and/or that I have no judicial cases pending which would invalidate my eligibility for exchange.
I hereby release information contained in my application, letters of recommendation, transcripts, and other information required
as part of the NSE application process to my home NSE Coordinator, designee, and those individuals/committees responsible for
reviewing and approving my application for exchange participation.
I hereby give permission for the information contained in my application to be submitted on NSE’s restricted, Web-based
placement site for the use of the home and host campuses and the NSE Central Office in placement and record-keeping
processes.
I hereby release information contained in my application, letters of recommendation, transcripts, and other information required
as part of the NSE application process to the NSE Central Office and to the NSE host institution at which I am placed.
*Signature _________________________________________________ *Date ____________________________
Supporting Materials or Other Requirements
APPLICATION FEE:
Please submit a check, for the non-refundable application fee in the amount of $200 to the Cohen Honors College,
Shocker Hall building A. Make checks payable to WSU-NSE.
PROGRAM OF STUDY STATEMENT:
This form must be completed. Please list your reasons for exchange, both academic and personal.
REFERENCE FORM:
Two reference forms must be completed. One of the forms MUST be completed by your academic advisor.
PERSONAL INTERVIEW:
Interviews are conducted the beginning of February. Trish Gandu will contact you to schedule your interview.
Signature
I have read and fully understand:
“How it Works” at nse.org
Campus policies and procedures governing my exchange participation
I further understand that:
Participating in the National Student Exchange is a privilege and not a right.
Submitting an application is not a guarantee of application acceptance or placement.
Failure to maintain (prior to and during my exchange) all of the eligibility requirements of the program and those of my home and host
campuses will result in the cancellation of my exchange.
Failure to maintain a cumulative 2.5 GPA as well as have a 2.5 GPA in the term prior to my exchange will result in the cancellation of my
exchange.
Failure to pay all financial obligations to my home and host campuses will result in the cancellation of my exchange.
Until financial obligations are met, my home and host campuses will not release transcripts; and I will not be permitted to re-enroll at,
or graduate from, my home campus.
My exchange is not completed until I submit to my home campus a transcript of my host campus work.
The NSE coordinator may use my name and placement information (once placed) on behalf of NSE promotional efforts. If accepted for
participation in the National Student Exchange, I agree to adhere to all the rules and regulations of both my home and host institutions.
Failure to do so will result in the cancellation of my exchange.
I affirm that all information is complete, accurate and true to the best of my knowledge. I acknowledge that I am signing freely,
voluntarily and under no compulsion.
*Signature _______________________________________________ *Date _______________________
*At the time of your interview, you will be required to sign and date this form.
Email completed form to trish.gandu@wichita.edu or drop off at the Cohen Honors College, Shocker Hall building A.
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Completed 18 July 2020

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