Application Deadlines Fall and Year-long programs: February 15 Spring programs: September 1

APPLICATION FOR PARTICIPATION ON EXCHANGE Office of International Programs & Services • P.O. Box 8106 • Statesboro, GA • 30460 Tel: 912-478-0332 • Fax: 912-478-0824 • Email: [email protected] • Web: georgiasouthern.edu/studyabroad

PART I – Intended Academic Semester or Year of Exchange Fall Semester 20____ Spring Semester 20____ Full Academic Year: Fall 20____ & Spring 20____ Name of prospective host institution: _____________________________________________

PART II – Personal Information __________________________________________ First Name

__________________________________________ Last Name

__________________________________________ Eagle ID

___________________________________________ Major

__________________________________________ Minor

__________________________________________ Current Class Standing

__________________________________________ Expected Term of Graduation

__________________________________________ Current GPA

__________________________________________ Country of Citizenship

Date of Birth: _______/_______/_______

Gender: ______ Male

______ Female

Part III – Contact Information [email protected] Email Address

__________________________________________ Alternate Email Address

_____________________________________________________________________________________________ Street Address (where all correspondence may be mailed) _______________________________ City _______________________________ Telephone (with area code)

_________________ State

____________ Zip Code

Part IV – Background information Type “N/A” if you have no answers/information to provide for the following questions. 1. Other institutions previously attended. Please include dates of attendance and any degrees awarded. ____________________________________________________________________________________ ____________________________________________________________________________________

2. Explain any and all experience you have with the culture and language of your selected country. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

3. Explain any previous travel abroad experiences. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

4. Describe your interests and hobbies. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

5. List the clubs or organizations you are active in on campus and in the local community. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Part V - Signature The statements contained in this application are true and accurate to the best of my knowledge, and I certify that I am signing as the individual who wrote and completed this application form. Signature of Student Applicant: ____________________________________

Date: _______/_______/_______