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This application must be completed and forwarded to Columbus State Community College International Initiatives and Community Outreach office.

The application is also available in in PDF format.  You can complete the form, print, sign and return it to:

Columbus State Community College
Dr. John W. Francis, Biological and Physical Sciences, NH493
550 East Spring Street, P.O. Box 1609
Columbus, Ohio 43215

Application in PDF format
   You must install the Adobe Acrobat Reader to view the PDF
   document. 

Personal Information

  Country of Citizenship: 
  		Specify Country of Citizenship:  
 Specify Country of Birth:   
 
  Date of Birth: 
 
Social Security Number: 
  --
Sex:  Male Female
  If not a US Citizen, indicate your Immigration Naturalization Classification below:

  Permanent Resident   Refugee   Student Visa Holder   Other Visa Type

Last Name:
First Name:
  
MI:
Home Address
                         Address:
                               City:

 

   State:    Zip Code: 
         Home Phone/email:

 

    E-mail: 
   Best days/times to call:   May we release your name, 
  address, and phone number 
   to other participants?
  Yes  No		  

Work Address

          Employer Name:
                   Your Title:
                     Address:

 
                           City:

 

   
                         State:

 

   Zip Code: 
              Home Phone:  Work Phone:
                        E-mail:

Emergency Contact  In case of an emergency, complete the following information.

             Contact:

   Relationship 

             Address:

                   City:   State:    Zip Code: 

       Home Phone:   Work Phone:   

                 E:mail

Dietary Considerations  

          Check one:

 

 Meat    No red meat    No pork    No restrictions
Other considerations:

 

Lodging Considerations

Do you smoke?

 

   Yes   No   Can your roommate/host family smoke?     Yes   No  
How do you feel about  staying with a family with small children?

 

   I prefer it     I don't care   I'd rather not!
Do you prefer to stay with a specific family?

Any other special  requests?

Medical Information
Identify any medications being taken:

Identify allergies: 

Identify any health or physical conditions:

            

 
Department Home
Contact Information
Jamaica Home		 Discovery Bay Jamaica