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NSE Application – page 1 of 4 Prior to completing this application, read: • NSE eligibility requirements, policies, and procedures in the printed NSE Directory (Sections “Application” through “During Exchange”.) or at nse.org, Students, How NSE Works. • Campus NSE policies and procedures Return This Form To: Dahlia Stridiron Patricia Towal Counselor Supervisor Counselor Supervisor Counseling and Placement Office University of the Virgin Islands #2 John Brewer’s Bay RR1, Box 10000 St. Thomas, VI 00802 Counseling and Career Services Kingshill, St. Croix 00850-9781 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 _________________________________________________________ Current Phone ______/_______________ extension ___________ Permanent Phone ______/______________ Alternate/Cell Phone______/_________________________ E-mail ________________________________ Alternate E-mail ___________________________________ Campus I.D. Number ___________________________ Demographic Information Date of Birth (MM/DD/YYYY): ________________________ Gender:  Female  Male 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 for Exchange Deadline for Priority Placement: _______________ Application Deadline: ________________________ Date Application Submitted: __________ Nonrefundable Application Fee Received: _______ 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. NSE Application – page 2 of 4 Demographic Information, continued 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 requesting financial aid (Plan A) from the host campus?  Yes  No Are you currently receiving financial aid?  Yes  No Where do you plan to reside at the exchange school?  Residence hall  Sorority/Fraternity  Off-campus Are you currently enrolled in the honors program?  Yes  No 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):  Yes  No If yes, name of the student(s) ________________________________________________________________ Name of campus at which the student is enrolled: ________________________________________________ Exchange Requests Period of requested exchange:  Fall Semester 20____  Spring Semester 20___  Fall Quarter 20___  Winter Quarter 20____  Spring Quarter 20_____  Summer 20____ List in priority order the institutions you wish to attend and the tuition payment plan(s) you could use. NOTE: Costs for room and meals are paid to your host campus regardless of which tuition payment plan you select. (Use an additional sheet if more than five institutions are requested.) Name of Institution Tuition Payment Plan Plan A=You pay resident (in-state/in-province) tuition/fees to your host campus. Plan B=You pay your normal tuition/fees to your home campus. 1. ____________________________________________ ___A only ___B only ___A or B (prefer ___) 2. ____________________________________________ ___A only ___B only ___A or B (prefer ___) 3. ____________________________________________ ___A only ___B only ___A or B (prefer ___) 4. ____________________________________________ ___A only ___B only ___A or B (prefer ___) 5. ____________________________________________ ___A only ___B only ___A or B (prefer ___) 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. 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?  Yes  No If yes, please explain: Are you currently under any campus disciplinary action for violation of codes of academic or student conduct?  Yes  No If yes, please explain: Do you have any outstanding indebtedness to the campus?  Yes  No 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, at least one faculty/staff member, and one other person who will recommend you for exchange. advisor department/office phone e-mail faculty/staff department/office phone e-mail name relationship to applicant phone e-mail Emergency Contact Name _________________________________________________ Relationship ________________________________ Street _____________________________________________________________________________________________ City, State/Province, and Zip/Postal Code ________________________________________________________________ Land-line Phone ______/___________ Cell Phone______/___________ E-mail __________________________ NSE Application – page 4 of 4 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 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 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 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 National Student Exchange Central Office and to the NSE host institution at which I am placed. Signature _________________________________________________ Date ____________________________ Supporting Materials or Other Requirements • unofficial transcript • recommendations/references • program of study statement • statement of personal goals and reasons for exchange participation • language proficiency report (if applicable) • interview Signature I have read and fully understand: • information on eligibility, policy, and procedures presented in the printed NSE Directory (Sections “Application” through “During Exchange”.) or at nse.org, Students, How NSE Works. • 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 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. 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 _______________________