Name of student:_____________________________________________________________ Date of Birth:__________________
Family First Middle
Permanent address in home country:__________________________________________________________________________
________________________________________________________________________________________________________
E-mail address:________________________________________________________
Do you plan to enter the U.S. from abroad? No Yes
Do you currently hold a U.S. visa? No Yes If yes, type of visa:_________________
Name of school that issued your last I-20 or DS-2019:___________________________________________________
If in the U.S., give your SEVIS I.D. number:_____________________________________________________________
If you plan to bring dependents, list their names and birthdates in the space below. Provide evidence that approximately
$4,000 per year/per dependent is available above the amount required for yourself:
Name SEVIS I.D. # Birthdate Country of Birth Country of Citizenship Relationship