Exchange Student Application Packet

Transcription

1 Exchange Student Application Packet Part II: Please note: Visa and Finances Insurance Immunization The documents in Part II of the Exchange Student Application Packet may NOT be submitted electronically.

2 Instructions for Completing Part II of Your Exchange Student Application Part II of the Baruch College Exchange Student Application Packet includes the following forms: a. The Confidential Declaration and Certificate of Finance (plus the required original documentation) b. The Affidavit of Personal Sponsorship, if you have one submitted (plus the required original documentation) c. The Exchange Student Health Insurance Verification Form d. The Exchange Student Health Insurance Certification Form e. The Baruch College Immunization Record The forms in Part II can be partially completed and saved as a PDF file electronically using Adobe Reader. However, the forms in Part II may NOT be submitted electronically. All forms must be printed out, must bear original signatures (in blue ink), and must be returned in paper form to the Director of Study Abroad. If you do not currently have the most current version of the free Adobe Reader software on your computer, you can download it at Further explanations of the forms in Part II and instructions on how to complete them are available online at You are strongly advised to read these instructions as well. The following instructions are meant to supplement those contained on the web site. Please read and follow them carefully before submitting the forms in Part II. 1. Electronically fillable PDF forms allow you to use Adobe Reader to fill in the highlighted fields on the form on a computer screen. To do so, open the file in Adobe Reader and move the cursor to the highlighted fields and fill in the values, or use the Tab key to move through the fields. 2. Some of the fields require that you enter the data in specific formats (for example, dates in the form of MM/DD/YYYY), but otherwise fill out the highlighted fields in much the same way you would if using a typewriter. 3. Please note: Many places on the forms (for example, places for original signatures and the dates beside them; entries regarding your immunization, etc.) have been deliberately left without a fillable field. Whenever required, these spaces must be completed by hand. 4. You can also save the entries you made in the file electronically using Adobe Reader. When you attempt to save your work, you will be prompted to save the open file. Reader allows you simply to overwrite the name of the PDF file you have open; however, you may create a new file, but the name must contain the text string Part II of the Baruch College Exchange Student Application. 5. You can fill in part of Part II, save your work and make additions later. However, whenever you attempt to save the file, you will be prompted again to save your changes to a new file. You can overwrite the saved file, or create a new one, if you prefer. 6. Please complete the following forms (or have them completed, if applicable) and submit them in paper form as soon as possible, but no later than October 15th for entry in the following spring semester or April 15th for entry in the following fall semester (these deadlines are later than those for Part I): a. The Confidential Declaration and Certificate of Finance (plus the required original documentation) b. The Affidavit of Personal Sponsorship, if you are having one submitted (plus the required original documentation) c. The Exchange Student Health Insurance Verification Form 7. Please send all completed forms and supporting documentation for Part II to the following address: Dr. Richard Mitten Director of Study Abroad Baruch College, City University of New York One, Bernard Baruch Way Box J-0810 New York, NY USA Tel Please note: You are NOT required to submit the following forms by October 15th/April 15th: d. The Exchange Student Health Insurance Certification Form You should purchase your health insurance only after you have been issued a visa. You must purchase a policy that provides the coverage listed on the form in the Part II application packet, and you must be covered by insurance for the entire period of your stay in the United States. In other words, you will need to purchase insurance, and prove that you have insurance, before you arrive in the U.S. A scanned copy of Exchange Student Health Insurance Certification Form, along with information about the policy you have purchased, should be sent to the Study Abroad Office (study.abroadxc@baruch.cuny.edu) before you depart for the United States.

3 Instructions Page 2 e. The Baruch College Immunization Record Please make sure to follow the instructions for completing the Immunization Record. You are REQUIRED to submit a scanned copy of your completed Immunization Record to Dr. Richard Mitten (Richard.Mitten@baruch.cuny.edu). Please complete the form and submit it as soon as possible, but no later than November 30th for entry in the following Spring semester or June 1st for entry in the following Fall semester. Failure to comply will result in removal from the program and cancellation of your DS Failure to properly complete and submit the forms in this packet in a timely manner will delay the processing of your visa documents. Failure to submit the Health Insurance Certification Form or the Immunization Record could place you in violation of your immigration status and/or make you subject to dismissal from the College and subject to deportation. Please take the completion of these forms very seriously.

4 Confidential Declaration Page 1 CONFIDENTIAL DECLARATION AND CERTIFICATE OF FINANCE One Bernard Baruch Way Box H-0880 New York, NY Tel: Fax: INTERNATIONAL STUDENT SERVICE CENTER J-1 Student Visa Type: F-1 (For ISSC Office Use Only: Student Applicants should NOT fill out this area) This declaration is for visiting international exchange students who plan to study at Baruch. Before you answer the declaration on this form, look at the chart below that tells you how many U.S. dollars you will need for tuition and other expenses for each academic year. A Certificate of Eligibility (Form DS-2019 or I-20) will not be issued until the student and his/her sponsor(s) have signed this form and returned it to the Weissman Center for International Business. PLEASE PRINT YOUR NAME AS IT APPEARS IN YOUR PASSPORT: NAME: Last (Family) Name First Name DATE OF BIRTH: / / Month Day Year Middle Name(s) ADDRESS: PHONE: COUNTRY OF CITIZENSHIP: COUNTRY OF BIRTH: SCHOOL LAST ATTENDED: DATES: FROM I.N.S. ADMISSION: SOCIAL SECURITY #: CURRENT U.S. IMMIGRATION.STATUS: MARITAL STATUS: SINGLE MARRIED TO IF SPOUSE OR CHILDREN WILL RESIDE WITH YOU IN THE U.S. PLEASE COMPLETE THE FOLLOWING: Dependent spouse and children of the F-1/J-1 student who are seeking entry/reentry to the U.S: Name: Last First Date of Birth Country of birth Relationship to student Name: Last First Date of Birth Country of birth Relationship to student ESTIMATE OF EXPENSES FOR AN INDIVIDUAL STUDENT AT BARUCH COLLEGE FOR THE ACADEMIC YEAR Books and Supplies Transportation Personal Expenses Housing Meals (at home) Lunch TOTAL (for one year) TOTAL (for one semester) UNDERGRADUATE $ 1, , , , , , $ 26,427.00** $ 13,213.50** GRADUATE $ 1, , , , , , $ 26,427.00** $ 13,213.50** ** ADD $11, per yr./$5, per 6 months for accompanying spouse ** ADD $6,000 per yr./$3, per 6 months for accompanying child PLEASE NOTE: THE CURRENT FIGURES ARE SUBJECT TO CHANGE

5 Confidential Declaration Page 2 CERTIFICATION FOR: DATE OF BIRTH: / / Last (Family Name) Middle First Month Day Year U.S.$ PER ACADEMIC YEAR SOURCES OF FUNDS A. PERSONAL OR FAMILY SAVINGS. Please send with this form a letter from your sponsor's bank stating in U.S. dollar equivalents the latest balance and HOW MUCH OF IT WILL BE USED TO COVER YOUR EDUCATIONAL EXPENSES PER YEAR B. YOUR GOVERNMENT (ONLY IF YOU HAVE FUNDS FROM YOUR GOVERNMENT). How much will your government pay for expenses while you are at Baruch? Print the name of the government agency that will pay your expenses per academic year. Enclose with this form a signed copy of your letter of award from the appropriate government agency to certify the accuracy of your award. Name of Government Agency C. OTHER SOURCES OF INCOME, i.e. loans, personal income, or travel grants. Please be specific: D. WILL YOU RECEIVE ROOM AND BOARD FROM A FRIEND OR RELATIVE? If so, include a signed letter from that person. Room and Board is worth $15,500 towards expenses. TOTAL (A+B+C+D) I/We hereby certify that the above information is accurate and that I/We is/are aware of the full cost of education at Baruch College as outlined on the reverse side of this form and that the funds are available and will be provided for the entire course of study. STUDENT'S NAME (PLEASE PRINT) STUDENT'S SIGNATURE SPONSOR'S NAME (PLEASE PRINT) SPONSOR'S SIGNATURE ADDRESS DATE RELATIONSHIP TO STUDENT NOTES REGARDING FURTHER DOCUMENTATION - Official and original documents must be provided. All documents must be in English and in equivalent U.S. dollars (or the current exchange rate must be supplied by the bank). If not possible, translations of documents will be accepted if signed and sealed by an appropriate government or bank official. All supporting documentation must not be older than three months. REVISED 09/2014

6 AFFIDAVIT OF PERSONAL SPONSORSHIP (Please have completed only if the source of any funding for your expenses during your stay is a family member or friend.) SPONSOR INFORMATION (Last /Family Name (First /Given Name) (Middle Name[s]) (Address 1) (City) (Address 2) (Country) DATE OF BIRTH: / / Month/ Day /Year ) Gender Female (Postal Code) Male CERTIFICATION OF SPONSORSHIP I hereby certify that I am able, willing and do commit to provide, (Name of exchange student) who will be participating in the exchange program with Baruch College during the Fall semester 20 Spring semester 20 (check all that apply) with the amount of US$ (Amount written in words) I currently have US$ (Amount written in words) (in numbers) (in numbers) in my account with (Name of bank) (City) (Address of bank). (Country) I have attached a bank statement issued within the past 90 days, validated by a bank officer and translated into English if not already in English. I certify that the information given above is accurate to the best of my knowledge. I agree to inform the International Student Service Center at Baruch College of any changes to my legal or financial situation that could affect my ability to fulfill my obligations as sponsor for the above-named student (Signature) (Date)

7 Health Insurance Verification and Certification Page 1 EXCHANGE STUDENT HEALTH INSURANCE VERIFICATION FORM Please read the following and sign. I understand that as an exchange visitor I must maintain health insurance for myself and my J-2 dependents. I have read and understood the accompanying excerpt regarding Insurance Coverage for J-1 Students. (The same coverage requirements also apply to holders of F-1 visas.) I, agree that I will be in compliance with the PRINT NAME insurance regulations as specified in section of the exchange visitor regulations, and I understand that it is my responsibility to maintain this coverage for myself and any J-2 dependents throughout my J-1 program. Upon arrival at Baruch College I will provide the Study Abroad Office with the documentation of my insurance (please see attached sheet to see what coverage is required). I understand the failure to comply with this provision of U.S. immigration law will place me in violation of my J-1 status and make me subject to deportation. / / MM DD YYYY STUDENT SIGNATURE Please return this to the Baruch College Study Abroad Office along with your J-1 Confidential Declaration and Certificate of Finance form and financial documents. Study Abroad Office Baruch College One Bernard Baruch Way, Box J-0810 New York, NY USA study.abroad@baruch.cuny.edu

8 CERTIFICATION OF INSURANCE COVERAGE (To be completed by all Exchange Students with J-1 Status attending Baruch College) Required Insurance Coverage for Students with J-1 Visa Status Exchange students are required to have medical insurance in effect for themselves and for any accompanying spouse and/or other dependents on J visas. You are required to have acquired this insurance before your arrival in the United States. Minimum Coverage Exchange students must have insurance that provides the following minimum coverage: (1) medical benefits of at least $100,000 per person per accident or illness (2) repatriation of remains in the amount of $25,000 (3) expenses associated with medical evacuation in the amount of $50,000 Additional Terms The policy should NOT have a deductible that exceeds $500 per accident or illness, and must meet other standards specified in the regulations. Maintenance of Insurance Exchange students must maintain the required insurance during the duration of their program. Baruch does NOT provide insurance coverage for any of its students; exchange students must therefore purchase medical, accident and emergency insurance. **************************************************************************** Name (please type or print legibly): (Last Name[s]) (first name) Home University: Term(s) attending: Dates of Program on DS-2019: From: (Month/Day/Year) Fall Spring to (Month/Day/Year) Insurance Policy Information Please complete the following information. You are required to attach a photocopy of the receipt of the policy you purchased or other evidence of adequate coverage. Company: Address: Policy Number: Dates of Enrollment: Please read, sign, and date, and return this original signed copy to the Baruch Study Abroad Office: I hereby certify that I have obtained health and accident insurance coverage for myself and for any dependents traveling with me for the entire period I will be in the United States under the auspices of the J-1 Exchange Visitor Program at Baruch College, Exchange Student Signature (please sign in BLUE ink) Date

9 IMMUNIZATION RECORD (Return the completed form to the Undergraduate Admissions Office before registration) Medical Unit Undergraduate Admissions One Bernard Baruch Way New York, NY Box H-0720 Phone: Fax: or IMMUNIZATION CERTIFICATION Social Security # - - (Return the completed form to the College Health Center before registration) Part 1: To be completed by the student LAST NAME (PLEASE PRINT) FIRST NAME M.I. ADDRESS APT # CITY STATE ZIP ( ) DATE OF BIRTH (MM/DD/YR) DAY PHONE ADDRESS If you have attended another CUNY college, please name the college: MENINGOCOCCAL MENINGITIS To be completed and signed by student or parent/guardian for students under the age of 18 I have read the meningitis disease information sheet, and I (my child) will not receive the vaccine. I had the Meningococcal Meningitis Immunization (Menomune) within the past 10 years. Date received Month/Year Student s Signature (Parent s signature for students under 18 years) Date NYS Public Health Law 2165 requires that postsecondary students who are enrolling for six or more credits must show protection against measles, mumps, and rubella. Persons born prior to January 1, 1957 are exempt from this requirement. Part 2: Immunization History - to be completed by a Health Care Provider. Signature and stamp required. Month/Day/Year MMR (Measles, Mumps, Rubella) If given instead of individual immunization. Date of 1st vaccine (12 months after birth or later, AND on or after January 1, 1972) Date of 2nd vaccine (15 months after birth or later, AND at least 28 days after 1st vaccine) MEASLES (Rubeola) Date of 1st vaccine (12 months after birth or later, AND on or after January 1, 1968) Date of 2nd vaccine (15 months after birth or later, AND at least 28 days after 1st vaccine) -or- Attach copy of Positive lab results for Measles titer RUBELLA (German Measles) Date of one vaccine (on or after 1st birthday or later, AND on or after January 1, 1969) -or- Attach copy of Positive lab results for Rubella titer MUMPS Date of one vaccine (on or after 1st birthday or later, AND on or after January 1, 1969) -or- Attach copy of Positive lab results for Mumps titer ACCEPTABLE PROOF OF IMMUNITY MAY INCLUDE: 1. Immunization cards from childhood. 2. Immunization records from college, high school, or other schools you attended. 3. Immunization records from your Health Care Provider or clinic. Include official stamp (In English) SIGNATURE OF HEALTH CARE PROVIDER / / DATE