International Student Admission Application
I-20 MAILING INSTRUCTIONS FOR APPLICANTS OUTSIDE THE UNITED STATES
For international applicants who currently reside outside the U.S., the I-20 is sent by U.S. airmail to your mailing address,
or to the permanent address if no mailing address is available. SIUE provides expedited shipping of your I-20 and admission
letter to you at no cost. SIUE uses an express mail service that will allow you to receive your acceptance letter and I-20
through DHL or FedEx in 3-5 days. Requesting your immigration documents through express mail is your responsibiilty
and details can be found at siue.edu/internationalstudents. Also, we do permit you to designate a representative (relative
or friend) currently residing in the U.S. to receive your I-20 so that special mail service can be arranged by this person.
Please indicate below where your I-20 should be mailed:
Campus Box 1047 l Edwardsville, Illinois 62026-1047
Phone: (618) 650-3770 l Email: [email protected] l siue.edu
I am applying as:
q Undergraduate/Bachelor’s Degree q Graduate Degree
Read the entire application and instructions before beginning. The family name, personal name and middle name
_____ Please send my I-20 directly to me at the mailing address listed on my application for admission.
must match on all other documents.
_____ I am authorizing the following person, who is currently in the U.S., to be my designated representative. Please
send my I-20 to this person so that special mail service can be arranged. I also authorize this person to contact you
concerning the status of my application. (Please note that only you and your designated representative will be authorized
to verify your admission status. Your representative must have your Social Security Number or Student identification
number in order to request information about your admission file.)
1. Name: ____________________________________________________________________________________________
Designated Representative: _________________________________________________________________________________
6. Permanent Address (must be your home country permanent address):
Family Name
Personal Name
Family Name
Middle Name
________________________
Date
DISCLOSURE (siue.edu/disclosure)
Southern Illinois University Edwardsville (SIUE) prohibits discrimination on the basis of age, color, disability status,
gender, marital status, national origin, race, religion, sex (including sexual harassment and sexual assault), sexual
orientation or veteran status regarding, but not limited to, the administration of educational programs, admission of
students, employment actions, athletics or other sponsored activities.
The University complies in letter and spirit with appropriate federal and state legislation, including, but not limited to,
Titles VI and VII of the Civil Rights Act of 1964, Title IX, the Americans with Disabilities Act (ADA) and the Illinois Human
Rights Act. Inquiries regarding the University’s obligations as an equal opportunity and affirmative action institution
should be directed to the Assistant Chancellor for Institutional Compliance, Rendleman Hall, Room 3310, Campus Box
1025, Edwardsville, IL 62026-1025, (618) 650-2333.
SIUE is committed to student privacy and confidentiality of information. Although submitting your Social Security number
is voluntary, it is recommended because the Social Security number expedites matching of credentials for admission
review and processing. It is also required of those students applying for financial aid. SIUE also needs your Social Security
number in order to furnish Form 1098T, Tuition Payments Statement, used to claim an income tax credit for the Hope and
Lifetime Learning Education Credits. Your Social Security number will not be shared with any third party without your
knowledge.
In accordance with Illinois State law, the SIUE Police Department shall disclose the name, address, date of birth, place of
employment, school attended, and offense or adjudication of all sex offenders required to register under Section 3 of the
Sex Offender Registration Act [730 ILCS 150/3] upon request. Please contact the SIUE Police Department for all questions
and/or inquiries.
The SIUE ANNUAL SECURITY REPORT is available online at siue.edu/securityreport. The report contains campus safety
and security information and crime statistics for the past three calendar years. This report is published in compliance with
federal law, titled the “Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act.” You also may
access this report online at: siue.edu. For those without computer access, a paper copy of the report may be obtained from:
Office of the Vice Chancellor for Administration, Rendleman Hall, Room 2228, (618) 650-2536.
4. Gender: _____ Male _____ Female
5. Country of Citizenship:____________________________
Street AddressCity
Postal or ZIP Code
______________________________________________________________________________________________________
Email Address: ___________________________________
_______________________________________________________________
Signature of Applicant
State
3. Country of Birth:__________________________________
_____________________________________________________________________________________________________
State/ProvinceCountryPostal or ZIP Code
* Attach Application Fee Payment Here *
Phone Number: _____________________________________
City
Middle Name
2. Date of Birth:__________/_______/_____________
MonthDay Year
Address: _________________________________________________________________________________________________
Street Address
Personal Name
7. Mailing Address (if in U.S., must be your current residence; P.O. Box may not be used):
All I-20s will be mailed to permanent address unless otherwise noted.
______________________________________________________________________________________________________
Street AddressCity
_____________________________________________________________________________________________________
State/ProvinceCountryPostal or ZIP Code
8. Visa type you plan to use at SIUE:
(Permanent residents of the U.S. must provide a copy of their Alien Registration Receipt Card I-551)
_____ F-1
_____ J-1
_____ Other___________________
Specify Type
9. If you are currently in the United States, what is your current visa type: (select one):
_____ F-1
_____ J-1
____________________________________________________________________________
Name of school that issued your current I-20/DS2019
_____ B1/B2_____ Other ____________________________________________________________
Specify Type
10. U.S. Phone Number (if available): ______________________________________________________________________
11. Email Address: _____________________________________________________________________________________
12. Semester/Year of requested admission (example: 2014 Fall/August):
_____ Fall/August
_____ Spring/January
_____ Summer/May
FOR UNDERGRADUATE STUDENTS:
13. Are you transferring from another U.S. Institution?
____ Yes
____ No
14. Requested Major (for a listing of undergraduate majors, visit siue.edu/academics): ________________________________
PLEASE CONTINUE ON THE BACK OF THIS PAGE
FOR GRADUATE STUDENTS:
15. Select the graduate degree program to which you wish to apply (refer to the listing of graduate majors at siue.edu/academics):
____ Master’s/Specialist
Major:_______________________________ Degree (MS, MBA, SD, etc.): ____________
Concentration or Teaching Field (if appropriate):___________________________________
Campus Box 1047 l Edwardsville, Illinois 62026-1047
Phone: (618) 650-3770 l Email: [email protected] l siue.edu
____ Post-Baccalaureate Certificate / Concentration: _______________________________________________________
____ Post-Master’s Certificate / Concentration: ___________________________________________________________
16. This section should be completed only by applicants who have had prior enrollment at SIUE as a graduate student but
have not been enrolled for the past three semesters or by currently enrolled graduate students seeking a new or second
major.
Check the appropriate category:
___I am applying for the same graduate major on record for my last term of enrollment at SIUE (for returning
students only).
___I am applying for a new graduate major and understand that my current graduate major on record will be
dropped (for returning and currently enrolled graduate students).
___I am applying for a second graduate major and understand that my current graduate major will be retained
(for currently enrolled graduate students only).
ACADEMIC HISTORY:
17. This section must be completed by all applicants. Please list all institutions attended beginning with secondary schools
to the present. Please list in chronological order. It is essential that we have your complete academic history, including
the dates of attendance and the exact title of any diploma or certificate earned or planned with the appropriate date (i.e.,
General Certificate of Education, Secondary School Leaving Certificate, Higher Secondary School Certificate, Matriculation
Certificate, etc.). Missing information will delay the review of your application.
Secondary Schools Attended Through High School
Name of School
City, State and Country
From
To
(no abbreviations)
Mo / Yr
Mo / Yr
All applicants must submit proof of adequate financial resources. Financial arrangements must be approved in advance of admission.
Complete all items on the form in ink. Use additional forms if you have more than one sponsor. Missing information will delay the
review of your application. Please note that the form is not considered complete until both applicant and sponsor have provided
proper signatures in the certification section, and the sponsor has provided a current bank statement or award letter (for scholarships,
grants and loans) verifying available funds. This form and all appropriate financial documents must be returned to the above
address. For additional information, call (618) 650-3770 or email [email protected].
1. Name of Applicant (please print): ____________________________________________________________________
Personal Name
Middle
Family Name
2. Applicant’s U.S. Social Security Number (if available, voluntary) See Disclosure Statement:____________________________
3. Applicant’s Date of Birth (mo/day/yr): _________________________________________________________________
4. Name of Sponsor (print): _______________________________________ Relationship: __________________________
5. Address of Sponsor: ________________________________________________________________________________
_____________________________________________________________________________________________________
List Diplomas / Certificates / Etc.
Earned or Planned and Dates
(use complete titles)
6. Funds (in U. S. dollars) that will be provided, per year, by sponsor: ___________________________________________
7. Indicate Source of Funds: ______ Family Funds
______ Personal Funds
______ Scholarship/Grant/Loan
_____ Other (please explain): _____________________________________________________________________________
8. List any dependents (spouse or children) accompanying you to the United States:
Post-Secondary Schools Attended with Degrees, if any
Name of School
City, State and Country
From
To
(no abbreviations)
Mo / Yr
Mo / Yr
(Please note that additional funds are required for dependents; if more space is required, list additional names on a separate attachment.)
List Diplomas / Certificates / Etc.
Earned or Planned and Dates
(use complete titles)
Name (Family / Personal / Middle )
Date of Birth
Country of Birth
Relationship
CERTIFICATION:
1. The application must be signed and dated by the applicant before action can be taken. Southern Illinois University Edwardsville
18.
is committed to maintaining a safe environment for all members of the University community. The University requires
applicants who are under current indictment or have been convicted of a crime (other than a routine traffic offense or in a
juvenile proceeding) to disclose this information as a mandatory step in the application process. A previous conviction or
current indictment does not automatically bar admission to the University, but does require review. Complete information
must be sent by Certified Mail at the time of application for admission to: Southern Illinois University Edwardsville; Office of
Admissions/Review Committee; Campus Box 1600; Edwardsville, IL 62026. Applicants are responsible for verifying receipt by
the University and for maintaining a copy of the receipt certifying submission. Information to be submitted includes: a brief
explanation, a location (city, state, country) of conviction or current indictment, dates, and court disposition. This statement
also must include a grant of permission to the University for complete access to criminal records, if any. For more information
about this requirement, call (618) 650-3705. I understand that withholding information requested on this application or giving
false information may make me ineligible for admission to the University or subject to dismissal. I certify that the statements I
have made on this application are correct and complete.
9. Applicant Certification: I hereby certify that the above statements concerning financial support are correct.
I also guarantee that the financial support indicated above is available to me.
____________________________________________________________________________
Signature of Applicant
Date
Signature of Applicant
Date
10. Sponsor Certification: I certify that I will provide sufficient funds to sponsor the applicant’s entire period of study
at SIUE. I am not merely acting as a guarantor, but I will actually remit the funds to the applicant while he/she is
studying in the United States. Furthermore, I agree to pay directly to the University all sums incurred by the
student if not paid by the student when due. I also agree to include with this form a bank statement verifying
available funds in the amount listed in #6 above.
Signature of Sponsor
Date
(over)