FLORIDA INTERNATIONAL UNIVERSITY

FIU CZECH STUDY ABROAD PROGRAM

SUMMER B TERM 2008

Website: www.fiu.edu/~weitzb/Prague-Study.htm

JUNE 25—AUGUST 3 2008

 

APPLICATION FORM

 

A deposit of $300.00 is required at the time of application.  This deposit will only be refunded if you are not admitted into the Program.  Please make check payable to FIU and write your Panther ID or social security number on the front of your check.

 

Name_________________________________________________________

                                                                                     

Date of birth ___________________________________________________                          

 

Panther ID (SS# if not FIU student) ________________________________          

 

Local address  _________________________________________________      

 

City  _________________________State  ______ Zip Code  ____________

 

Home Phone_________________________Cell_______________________ 

 

Email ________________________________________________________

 

Permanent address (if different from above)__________________________

 

 ________________________________

 

City  ___________________________State ______Zip Code  ___________

 

Phone_____________________ ______

 

Do you work?   YES  /  NO               Phone________________________

 

Citizenship  ____________________________Florida Resident        YES  /  NO 

 

Major  _____________ Minor ___________ Florida Prepaid Tuition YES / NO     

 

Present Status:   Freshman   Sophomore   Junior   Senior   Graduate   Special    Not currently enrolled         GPA _________

 

Passport:  You must have a passport (http://travel.state.gov/passport/passport_1738.html)that is valid for at least 6 months after the end of the Program.  U.S. citizens do not need a visa to enter the Czech Republic or Slovakia.  Non-U.S. citizens and Resident Card holders may need visas and should check with the Czech and the Slovak embassies in Washington or in their home countries.

Passport number________________________ Country________________

 

Expiration date  ________________________

 

Two contact names, addresses and telephone numbers (in case of emergency):

 

1.____________________________________________________________

 

_____________________________________________________________

 

2.  _____________________________________________________________

 

_____________________________________________________________

 

 

Have you been overseas before?  Where did you go and for how long?

 

_______________________________________________________________________

 

_______________________________________________________________________

 

How did you learn about this program? 

 

_____________________________________________________________

 

If you were to participate in the program, do you plan to travel elsewhere in Europe upon completion of the program?  ________.  If so, where do you plan to go?  _____________________________________________________________

 

We strongly encourage early application since space is limited and you will be able to take advantage of better air flight arrangements; priority will be given to qualified early applicants.

 

Do you have any medical condition that we should know about?  Please be specific.

 

 

 

 

Are you allergic to any medication?  Please explain.____________________

 

_____________________________________________________________

 

Physician’s Name____________________________________Phone_______________

 

 Payment:  Please make all checks for program cost and mail them or bring them to our office (DM 460).  Please write your Panther ID or social security number (if not an FIU student) on the front of every check.  Tuition will be paid at time of Registration for Summer classes and in your usual manner.

 

Program cost payments are as follows:      $300.00 with this application

                                                          $1350.00 March 01, 2008 

                                                          $1300.00 April 1, 2008

                                                          $1200.00 May 15, 2008

 

PLEASE NOTE:  The Program cost of $4150.00 does not include airfare, tuition and fees.  Financial Aid is available for all students who are eligible

 

Do you intend to apply for financial aid?              YES              NO

http://www.fiu.edu/orgs/finaid/

 

TUITION:  FIU tuition is for up to 9 credits

Applicants from SUS institutions should submit transient form in addition to FIU registration form. http://www.fiu.edu/orgs/register/forms/Transient%20Student%20Form.pdf

http://www.fiu.edu/orgs/register/Non_Degree_Form_Web.pdf

 

Applicants from other institutions should submit Florida residence (if applicable) and FIU registration forms. REFUND POLICY:  The $300.00 deposit fee that accompanies this application is non-refundable. If you withdraw from the Program for any reason from March 1 – April 1, 75% of the Program Fees paid will be refunded (except for the application fee).  From April 1 – May 14, 50% of the Program Fees paid will be refunded (except for the application fee). After May 15, NO REFUNDS.

 

Please read the following statement carefully:

 

“I understand that all Program Requirements, Policies and Rules as well as the FIU Student Code of Conduct must be observed by each participant.  Failure to follow Program Requirements, Policies or Rules or the FIU Code of Conduct may result in expulsion from the Program, loss of credits, forfeiture of Program fees or any other penalties provided in the Student Code of Conduct.”

 

Signature 

 

__________________________________Date_____________________

 

Please return completed application with the $300 fee to:

 

Prof. Barbara Weitz  

weitzb@fiu.edu        

(305) 348-3294                                                                          

DM 459 A

Florida International University

Miami, FL 33199