Forms: International Student & Scholar Information Request Form
International Student & Scholar Information Request Form
Print this form. All applicable questions must be answered. The form must be returned to the Office for International Students & Scholars before any paycheck is issued by the Payroll Department. A copy of health insurance proof for yourself and your dependents must be attached to this form.
Personal Information
| Student I.D.#: | |
| Last/Family Name: | |
| First/Given Name: | |
| Middle Name: | |
| Citizenship: | |
| Country of Birth: | |
| Sex: | |
| Date of Birth (m/d/y): | |
| E-mail Address: | |
| Department/Major: | |
| Adviser (if any): |
Address/Phone # Information
| Address in the U.S.: | |
| Phone Number on Campus: | |
| Home Phone: |
| Address in your home country: | |
| Phone Number: | |
| Fax Number (if any): |
Emergency Contact Information
| Name of Emergency Contact in the US: | |
| Address: | |
| Phone Number/s: | |
| Relationship: |
| Name of Emergency Contact in your home country: | |
| Address: | |
| Phone Number/s: | |
| Relationship: |
Family Information
If your family members are in the US, please give the following information. A copy of the Passport, I-94, Visa Page, Health Insurance (mandatory), and I-20/IPA-66, or I-797 must be attached.
| Name | Date of Birth | Visa Type | Country of Birth | Relationship |
|---|---|---|---|---|
Host Family (if any)
| Name: | |
| Address: | |
| Phone Number: |
IMPORTANT
TAX: If you wish to claim exemption from US income taxes because of your country of permanent residence has a tax treaty with the United States, you must complete IRS form 8233 and the appropriate revenue procedure. (Available through Payroll.)
INSURANCE: I understand that I am responsible for obtaining health insurance for myself and my dependents.
I hereby certify under the penalties of perjury that all the above information is true and correct. I understand that if my status changes from that which I have indicated on this form, I must submit a new International Student & Scholar Information Request Form to the Office for International Students & Scholars.
| Signature: | |
| Date: |
