Semester Exchange Contact Information

UCA students applying to study abroad for a semester or a year with partner universities.

Last name as it appears on passport: *
First name as it appears on passport: *
Middle name as it appears on passport: *
Name you prefer to go by *
Email *
Student ID *
Partner University (First choice) *
Study abroad Term and Year *
Partner University (Second choice) *
Study Abroad Term and Year *
Passport Number
U.S. Citizen * Yes No
If no, which country are you a citizen of? *
Birth Month * January February March April May June July August September October November December
Date of Birth: Day *
Birthday Year
*
Local Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Permanent Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone Number *
Classification * Freshman Sophomore Junior Senior Graduate Student
When do you plan to graduate? Term/Year *
Major *
Minor *
Cumulative GPA *
Have you studied abroad before? if so, please indicate when and where. *
Emergency Contact Information:
Name *
Emergency Contact Information:
Relationship *
Emergency Contact Information:
Cell Phone *
Emergency Contact Information:
Address *
Secondary Emergency Contact Information:
Name
*
Secondary Emergency Contact Information:
Relationship
*
Secondary Emergency Contact Information:
Cell Phone
*
Secondary Emergency Contact Information:
Address *
Agreement and Signature

By submitting this application, I affirm that the facts set forth are true and complete. I understand that if I am accepted as a Study Abroad participant, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal from the Study Abroad program.
Initials and Date