Int. student app.

International Student Application
Lorain County Community College
Office of International Recruitment & Student Support
1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America
Telephone: 440.366.4794, Toll Free: 1.800.995.5222, extension 4794, Online: www.lorainccc.edu
Personal Information
Name: ________________________________________________________________________________________________________
Address in Home Country:_________________________________________________________________________________________ City:________________________________State/Province/Country:___________________________Postal Code:__________________ Day Telephone ( )_________________________________Evening Telephone ( )____________________________________ U.S. Address (if known):__________________________________________________________________________________________ City:_____________________________________________State:__________________Postal Code:_____________________________ Country of Birth: ________________________________________________Date of Birth: ___________________________________ Country of Citizenship/Nationality: _________________________________________________________________________________ U.S. Social Security Number:__________________________________E-mail Address:________________________________________ Enrollment Intentions
What Semester Do you Plan to Begin? ❐ Fall (Aug.-Dec.) ❐ Spring (Jan.-June) ❐ Summer (June-Aug.) Year ___________________
Program of Study:___________________________________________ Initial Attendance ❐ Change of Status Requested ❐ School Transfer/School Name:______________________________________________________________________________________ Reinstatement Requested:______yes _______no Other:________________________________________________________________ Driver’s License Number/State of Issue:______________________________________________/________________________________ Language Information
Is English your 1st Language______yes ______no
If no, state your 1st language____________________________________________ Current Visa Status
If you are currently in the United States, what is your current visa type?___________I-94 Admission Number:________________________
Date of Entry:___________________________________________ Port of Entry:_________________________________________ Do you have a current F-1 visa?_______yes _______no If yes, institution that issued your I-20 Form_________________________ Have you attend that institution?________yes _______no Dates of Attendance: from_______ to_______ If yes, you must submit an ISO Report to Lorain County Community College.
Over please
Housing
Will you require housing? ______Yes, I will require housing ______No, I have housing supplied for me while in the United States
Education
List all schools, colleges and universities you have attended. Send original or certified copies of grade sheets,
transcripts, and final diploma or degree results for secondary and post-secondary education. Foreign transcripts
must be officially translated into English.
How did you learn about LCCC?__________________________________________________________
_____________________________________________________________________________________________
Briefly explain why you wish to study here:_______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Health Insurance Requirement & Acknowledgement
All international students attending LCCC must provide proof of Hospitalization and Accident Insurance for each semester they are attending classes.
PROOF OF INSURANCE IS REQUIRED PRIOR TO REGISTERING FOR CLASSES.
I, ___________________________________________ was informed of the International Students Health Insurance Requirements. I willprovide all required documents and understand that if I fail to comply with this requirement, LCCC will not allow me to register for classesuntil I provide all proof of insurance coverage or make arrangements to purchase the health insurance offered by LCCC.
Legal Signature
I certify that the information I have provided on this application is complete and accurate to the best of my knowledge. I understand that
falsifying any part of this application may be cause for refusal of admission, cancellation of admission, or dismissal from LCCC. By signing and
dating this application, I agree to abide by the policies and regulations of the college as published in the Lorain County Community College
Catalog.
Legal Signature: _________________________________ Parent/Guardian Signature: _________________________________ (Parent/Guardian required only if applicant is under 18 years of age) lnational Student Financial Statement
Lorain County Community College
Office of International Recruitment & Student Support
1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America
Telephone: 440.366.4074, Toll Free: 1.800.995.5222, extension 4074, Online: www.lorainccc.edu
Personal Information
(PLEASE TYPE OR PRINT CLEARLY)
Student’s Legal Name: ______________________________________________________________________________ Last/Family Name First/Given Name Middle Name Date of Birth: ________________________________ U.S. Social Security #: ____________________________ Mailing Address: ___________________________________________________________________________ _________________________________________________________________________________________________ City State/Province/Country Postal Code Telephone Number Country of Citizenship: _____________________________ Financial Information
(ALL AMOUNTS MUST BE STATED IN U.S. DOLLARS)
Student Savings
Fill in any amount in your own bank account to be used for expenses. Attach a statement from a bank official to verify that this amount is available in your account. $ ______________ Parent Savings
Fill in any amount your parent(s) will provide from their savings. Parent(s) must sign
this form and attach a statement from a bank official to verify that this amount is
available in the account.
Name of Parent(s): _________________________________________________ Parent’s Signature: _________________________________________________ Parent Funds (Not Savings)
Fill in any amount to be furnished by your parents that will not come from savings
(example: $200 per month - source father’s salary). Parent(s) must sign this form and
attach proof of source of funds (example: letter from father’s employer stating
monthly salary).
Name of Parent(s): _________________________________________________ Parent’s Signature: _________________________________________________ Other Source of Funds
Fill in any amount to be provided from other relatives, your government, a scholar-
ship, or any other source. Attach a statement to verify the amount that will be pro-
vided to you.
Source of Funds: _________________________________________________ U.S. Sponsor
Fill in amy amount you expect to receive from your U.S. Sponsor. Also indicate
support that is not in the form of money (example: room and meals). Sponsor must
submit an Affidavit of Support (form I-134)
Name of Sponsor: _________________________________________________ Sponsor’s Signature: _________________________________________________ VerificationHealth Status Verification Form
Lorain County Community College
Office of International Recruitment & Student Support
1005 Abbe Road North, Elyria, Ohio, 44035-1691, United States of America
Telephone: 440.366.4074, Toll Free: 1.800.995.5222, extension 4074, Online: www.lorainccc.edu
International Students
Report of Tuberculosis Testing
Before you can register for classes at Lorain County Community College, you must bring (DO NOT MAIL) the completed docu-
ment below showing that you are free from tuberculosis (TB) to the Office of International Recruitment & Student Support at
LCCC. You can obtain a skin test (for a minimal fee) at the County Tuberculosis Clinic located at 9890 South Murray Ridge
Road, Elyria. Their hours are as follows:
Tuesdays, Wednesdays, Thursdays & Fridays from 8:00 a.m. to 4:00 p.m.
You must return to the Clinic 48 to 72 hours after your test to have them fill out the information at the bottom of this form.
Take this form with you when you go.
If your skin test shows that you have been exposed to TB, the doctor at the Clinic will also get an X-ray of your chest (for a mini-mal fee) and will tell you how often you must have chest X-rays taken while you are a student at Lorain County CommunityCollege. The doctor may also advise you to take a medicine (Isoniazid) to prevent you from developing TB later in life. If youchoose to take the medicine, you can get it (for a minimal fee) from the County Clinic.
If you need further assistance in this matter, please contact the Office of International Recruitment & Student Support at LorainCounty Community College. Our telephone number is 1.800.995.5222 (extension 4074).
Testing Verification
Student's Name: ________________________________________
Student Number: ___________________________ Date TB Test Given (Mantoux Only): _______________________ Result: ___________________________________ Result of Chest X-ray: ___________________________________ Repeat: _____________________________Months Isoniazid recommended: _____ yes _____ no Signed: ________________________________________, M.D.
Date: ____________________________________ Location: ___________________________________________________________________________________________ Return Form
Bring this form to the Office of International Recruitment & Student Support at Lorain County Community College
Note on X-Rays
If an X-ray is done, please sign a release of information form at the TB Clinic so that a copy of the chest X-ray report can be
forwarded to LCCC.

Source: http://www.lorainccc.edu/NR/rdonlyres/53675D80-07B2-4039-ACBC-7349205FDA2F/0/InternationalApplicationv5.pdf