GEORGIA SOUTHERN UNIVERSITY
ENGLISH LANGUAGE PROGRAM
SEVIS Data Form Send completed form and financial documentation (see SEVIS Financial Documentation Requirements) to: English Language Program, Georgia Southern University, 847 Plant Drive, Box 8124, Statesboro, GA
[email protected] or 912-478-5555.
30460, U.S.A.
Submit questions to
P E RS ONA L I N FOR M A TI O N Name (must match passport exactly unless translation to English is required – submit a photocopy of your passport to help us enter your name correctly): Last Name (Surname or Family Name): First Name (First Given Name): Middle Names (Other Given Names): Date of Birth (month/day/year): / / Gender: City and Country of Birth: , Country of Country of Legal Permanent Residency: Phone Number (if outside the U.S., please provide the country code and the city code.) Email Address (important):
Male
Female _ Citizenship: _ _ _
Home address in your native country (This cannot be a U.S. address.): Address line 1: Address line 2: City: Postal code:
_ _ _
Province/Territory: Country:
_
You currently live: outside the U.S. inside the U.S. If you currently live inside the U.S.: 1. W ill you leave the U.S. before starting classes at Georgia Southern University? No Yes (Note: You must have your Georgia Southern I-20 to re-enter the U.S.) 2. W hat is your current visa status? (Example: F-1, F-2, B1/B2, H-4, J-1)
_
Will a dependent (wife, husband, child) come with you to the United States? Yes No If yes, provide the following information for each dependent. Use extra pages if necessary. (See SEVIS Financial Documentation Requirements.) Relationship:
Spouse (wife or husband)
Child
Last Name (Surname First Name Middle Names (Other Date of Birth (month/day/year): / / _ City and Country of Birth: Country of Citizenship: Country of Legal Permanent Residency:
Gender: or
Male Family
Female: Name): Name): Names):
(Given Given ,
_ _ _
P R O G RA M I NF O RM A TI O N Do you plan to enroll only in the ELP and then return to your country? Do you want to continue your studies at Georgia Southern? If yes, which major:
Yes
Yes
No
No
_
Undergraduate freshman can apply for conditional admission. Do you want conditional admission?
Yes
No
F I N A NC I A L D A T A Write the amount of money that will be available to you for your first year of study from each source. Personal Funds $
_
Scholarship/Loan $
Name of organization
_
Guarantor $ (Guarantor must complete statement below or provide a separate letter.) Guarantor's statement: Guarantor's last name (surname or family name):
_
Guarantor's first names (given names):
_
Address line 1:
_
Address line 2:
_
City:
Province/Territory:
Postal code: Relationship to student:
_
Country: Spouse
_ Parent
Grandparent
Uncle
Aunt
Brother Sister Cousin Friend I guarantee this student will have sufficient funds to pay all educational and living expenses while studying at Georgia Southern University. I understand that the estimated expenses shown on the SEVIS Financial Documentation Requirements are subject to increase annually, and I am guaranteeing funds for _ years. Guarantor's signature (required):
Date:
_
S T U D EN T C E R T I FI C A T I ON I acknowledge that I and/or my guarantor have enough money to cover my expenses while I am in the U.S. and that Georgia Southern University is not financially responsible for students. I understand that I must be officially admitted and provide acceptable financial documents before an I-20 or DS-2019 will be issued. I also understand that I may need to provide additional financial documents while I am in the U.S. or if I must update my admission to a later semester. I promise that the information provided on this form is true.
Student's Signature:
Date:
_
M A I LI NG A ND S HI P P IN G I N S TR U CT I ON S I-20 packets are sent using the United States Postal Service (AIR MAIL) unless you pay a shipping fee. Shipping is strongly recommended, unless you’ve sent all documentation at least 3 months before classes begin. NOTE: If selecting the shipping option, do not list a P.O. Box. Please list a physical address and phone number. Attention:
_
Phone Number:
Address line 1:
_ _
Address line 2: City:
_ State/Province/Territory:
Postal code:
_
Country:
I do not want my I-20 mailed or shipped. I want to make other arrangements.(Please specify)
I will pay by credit card online at https://touchnet.georgiasouthern.edu/C20795_ustores/web/store_main.jsp?STOREID=11
_ _ _
