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please print or type
Name (last, first, middle)
____________________________________________
Student's ID Number: ____________________
Passport Number ____________
Address__________________________________
City ___________ State
_____ Zip_____________
Day Telephone_____________________________
Evening Telephone_________________________
E-mail __________________________________
Date of Birth _____________________________
Citizenship _________________ Gender _______
State of Residence _________
Current Class Standing
(circle one):
Freshman / Sophomore / Junior /
Senior / Grad Student
Other (specify)____________________________
Major__________________Minor_____________
Expected graduation date:
___________________ Institution _______________
Emergency
Contact Name _____________________ Relation _______________
Home Number ____________________ Work Number
____________________
Address _________________________________________________________
If working, job title and brief
description of duties:
________________________________________________________________
________________________________________________________________
Countries Visited __________________________________________________
________________________________________________________________
Relevant Courses Taken_____________________________________________
Diet/Health Concerns _______________________________________________
How did you hear about this program? _________________________________
Reasons
for your interests in this program:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: __________________________
Date: __________
Submit to: Paula Huntley, 14th
floor, RCB Building, Institute of International
Business, 35 Broad St., Georgia State University,
University Plaza, Atlanta, GA 30303-3083.
Submit with a $250 deposit.
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