| University of Georgia Study Abroad Program Application
(printer friendly version. When printing, specify from pages one to seven.) Checklist
· Submit all of the following materials together
(except references, see below).
Make sure the following items are included in the materials
you return:
I further understand that the program may be cancelled
due to low enrollment or other factors and I understand that I will be
informed of such a decision no later than 6 weeks before planned departure
date or as soon as possible after any adverse circumstances that cause
the program to be cancelled.
Student Name ________________________Signature ___________________Date_________
For Study Abroad Program Use Only:
(page 2) For Office of International Education Statistical Purposes (optional) Ethnic Group: __American Indian __Asian or Pacific Islander __ Black, African American __Hispanic __Multiracial __White _________________________________________________________ Personal and Academic Information (required) Social Security Number: Full Name: Preferred Name: Birth Date___________________ Age ___ Sex: M F Mother/guardian’s Name: Father/guardian’s Name: Are you on financial aid (including HOPE) Yes No What types? Your college/univ.: Are you a Georgia Resident? Yes No GPA______ GPA in major_________ Major(s) Minor(s) Academic Level (during study abroad) Freshman Sophomore Junior Senior Master’s Ph.D. Campus Address: Phone: E-mail________________________________________
Citizenship__________________Passport Number___________________ Date of Issuance ___________ Passport Agency
__________________
(page 3) Name ________________________________ Dates: From ___________ to_____________ Degree(s) awarded _______ Major Name ________________________________ Dates: From ___________ to_____________ Degree(s) awarded _______ Major
Name ________________________________ Dates: From ___________ to_____________ Degree(s) awarded _______ Major
Why do you want to participate in the UGA-Morocco Program?
(We encourage you to use the back side when you run out of space here.)
Personal Activities
List the primary co-curricular activities in which you
are involved and in what capacity
Disciplinary Record
Have you ever been found guilty of violating any high
school, college or university regulations or the student code of conduct
for UGA or any other institution? ___ yes __ no
______________________________________________________
I hereby authorize officials at ________________________ to release my
disciplinary records (fill in your university's name)
(including but not limited to records maintained by the Judicial Programs
and Services Office, the Department of Housing, and/or the Office of the
Vice President for
Academic Affairs) to the study abroad program director of the program to
which I am applying.
I fully understand that my disciplinary records may be a factor in
evaluating my application.
I further acknowledge that the information provided on
this application is true and accurate to the best of my knowledge.
I fully understand that providing false information during the application
process may be grounds for rejecting my application or grounds for dismissal
from the study abroad program.
Student Signature_____________________________Date________________________
Applicants who are accepted to participate in a UGA study
abroad program are required by The University of Georgia to complete and
sign a student agreement and waiver which stipulates the terms and conditions
of the program, student conduct regulations and a waiver of liability.
Signature of Study Abroad Advisor/Dean/Academic Advisor (for non-UGA
students only)
Phone ________________________
E-mail______________________________
Signature
____________________________________
______________________________________________________________________
__poster
HOPE Scholarships for Non UGA-Students Enrolled at other USG
Schools
Name of advisor in your Financial Aid office with whom you have spoken______________.
Date on which you spoke with this advisor_____________________.
Direct phone number (plus extension, if any) of this advisor___________________.
Fax number of this advisor____________________.
Email address of this advisor_________________.
References
__Confidential file --- __Open file
Please obtain two references using the following forms
and either include them in your file, or have them sent directly to the
study abroad program office. References from faculty or employers are preferred.
References from friends, family, or neighbors are not acceptable.
______________________________________________________
(page 6) Applicant's local telephone________________________ E-mail_______________________
II. This section to be completed by the referee
Phone_______________________
E-mail___________________________
2. Is there any reason why you would not recommend that
the applicant participate in a study abroad program?
Please indicate your perceptions of the applicant's competence
in the following areas:
Other remarks may be written or typed on the back of this
form or on a separate sheet.
Signature of Referee
Date
Please notify the student when he/she may pick up
reference
or forward it to the address above.
_________________________________________________________
(page 7) Applicant's local telephone________________________ E-mail_______________________
II. This section to be completed by the referee
Phone_______________________
E-mail___________________________
2. Is there any reason why you would not recommend that
the applicant participate in a study abroad program?
Please indicate your perceptions of the applicant's competence
in the following areas:
Other remarks may be written or typed on the back of this
form or on a separate sheet.
Signature of Referee
Date
Please notify the student when he/she may pick up reference
or forward it to the address above.
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