University of California San Diego Study Abroad (UPS)

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1 Vejledning til udfyldelse af ansøgningsskema University of California San Diego Study Abroad (UPS) Dette ansøgningsskema skal udfyldes af alle ansøgere til UCSD - uanset om du søger ind på et Quarter, en eller to Summer Session(s), eller et Quarter OG en Summer Session. NB! Vær opmærksom på at Study Abroad-programmet på UCSD hedder University and Professional Studies (UPS). Søger du en Summer Session, skal du også udfylde det ansøgningsskema, der hedder Summer Session Supplemental Application for International Students. Side A1 HOW TO APPLY Hvis du er Study Abroad studerende, er det kun punkterne 1 og 4 som er relevante for dig (samt punkt 6 hvis du også søger Summer Session). Denne side er til information, så du bør læse de nævnte punkter, men den skal ikke vedlægges din ansøgning: Side A2 FREQUENTLY ASKED QUESTIONS Denne side er også til information og skal ikke vedlægges din ansøgning. Du bør læse punkterne A-H igennem, da det er relevant for din ansøgningsprocess. Under C (Cost Calculater) kan du se, hvordan UCSD er kommet frem til det beløb, som skal stå i bankbrevet eller Financial Verification delen af ansøgningen ( USD) - se side A4. Side A3 1 PERSONAL INFORMATION Udfyld med dit efternavn, fornavn(-e), fødselsland, fødselsdag, modersmål, adresse, statsborgerskab, postadresse i Danmark. Du skal ikke afkrydse boksen over feltet, hvor du skriver din adresse, men i stedet sætte kryds i boksen 'Address to which I-20 and acceptance materials should be mailed' (ovenover EDUs stempel). 2 PROGRAM INFORMATION vejledning@edu-danmark.dk Senest opdateret 8-Aug-14

2 Hvis du er Study Abroad ansøger, skal du angive hvor mange Quarters/Sessions du vil læse (1 Quarter = 1 Session osv.). Under University Credit Programs krydser du af ved University and Professional Studies, og angiver starttidspunkt. Starttidspunktet kan du finde under Studiestart på UCSDs profil på vores hjemmeside. Hvis du har læst på UCSD tidligere, skal du her angive hvornår. 3 TRANSFER STUDENTS Sæt kryds i No og gå videre til side A4, hvor du skriver hhv. dit efternavn og dit fornavn øverst på siden. Side A4 4 I-20 REQUEST Sæt kryds i Yes og ved for an F-1 visa. Financial Verification A. Din bank skal udfylde, stemple og underskrive denne del eller skrive et separat brev på engelsk om, at du kan dække omkostningerne til dit ophold. Brevet fra din bank er en vurdering din bank laver af dig, hvor de bekræfter, at så vidt de kan vurdere, har du nok penge til rådighed til at dække omkostningerne ved et studieophold på UCSD. Det samlede beløb du har til rådighed, skal overstige resultatet af regnestykket i punkt C (side A2) i ansøgningsskemaet. Dette beløb (eller større) skal stå i brevet, ellers kan det ikke godkendes af universitetet. OBS! Din bank skal altså ikke lave en bankgaranti. Din bankrådgiver skriver under på, at han mener, at du kan dække dine omkostninger, men hæfter ikke økonomisk for noget. B. Hvis én i din familie er økonomisk ansvarlig for dig, skal denne person udfylde dette punkt med navn, underskrift, relation til dig og dato. Du skal stadig vedlægge bankbrev (som beskrevet herover) eller få udfyldt Financial Verification i denne persons navn. DEPENDENTS Hvis du medbringer familiemedlemmer (ægtefælle eller børn), skal disse angives her. 5 PAYMENT PROCEDURE vejledning@edu-danmark.dk Senest opdateret 8-Aug-14

3 Kryds af ved University Credit Programs application fee. Vi anbefaler, at du også krydser af ved 3-day express mail delivery of I-20 for at sikre en hurtig levering dit I-20 dokument (som du skal bruge, når du skal søge om studievisum). Payment options UCSD foretrækker, at du betaler med betalingskort, så kryds af i relevant korttype. Udfyld kortnummer, kortets udløbsdato, beløb, navn underskrift på kortholder. 6 SIGNATURE Underskriv og datér din ansøgning. Side A5 MEDICAL INSURANCE VERIFICATION FORM Denne formular (side A5) skal du ikke udfylde/sende nu. Du skal have en sygeforsikring, mens du læser på UCSD. Du kan vælge at købe en forsikring gennem UCSD, eller du kan købe en dansk rejseforsikring hjemmefra, der opfylder de krav, der står under punkt 3: Insurance Coverage Amounts. Hvis du vælger at købe en dansk rejseforsikring, skal du sende denne formular, sammen med en engelsk version af din forsikringspolice, til UCSD senest 30 dage før studiestart - dog først efter du er optaget. Du udfylder selv punkterne 1 og 2 og derefter skal dit forsikringsselskab udfylde punkt 3/resten af formularen. Hvis du vælger at købe en forsikring gennem UCSD, skal du ikke sende denne formular. Side A6 TUBERCULOSIS (TB) QUESTIONNAIRE Denne formular (side A6) må TIDLIGST udfyldes 6 måneder før studiestart. Udfyld boksen øverst på siden. Hvis du svarer Yes til ét eller flere af spørgsmålene, skal du have foretaget enten en hud- eller blodprøve hos din læge. Hvis du søger mere end 6 måneder før studiestart, skal formularen eftersendes, da den ikke må være mere end 6 måneder gammel. Søger du senere end 6 måneder, vælger du selv, om du vedlægger den ansøgningen nu, eller eftersender den. vejledning@edu-danmark.dk Senest opdateret 8-Aug-14

4 ACKNOWLEDGEMENT FORM Den side hvor der står UNIVERSITY OF CALIFORNIA, SAN DIEGO (UCSD) øverst kaldes Acknowledgement Form, og denne side skal udfyldes før man kan blive optaget på UCSDs UPS program (Study Abroad). Så den skal udfyldes og vedlægges din ansøgning. Du skal skrive dine initialer ud for hvert punkt, underskrive og datére, og skrive dit navn med blokbogstaver. En del studerende har undret sig over disse punkter: I will achieve final grades of A or B in all of my classes. I will be placed on academic probation if I receive a final grade of B- or below in any class. I acknowledge that if I receive a B- or below while on academic probation I will not be able to continue in the UPS program. UPS students will receive a certificate if all of their grades are A or B. UPS students who receive a final grade of B- or below in any class will not receive a certificate. Selvom man ikke får A og B, kan man stadig få et transcript (men ikke et certificate), så man kan få meritoverført sine fag. Probation er kun relevant, hvis man skal være på UCSD i mere end én Session. EDU har ikke erfaret, at dette er et problem. De fleste studerende klarer sig fint på UCSD, men det skal understreges, at UCSD forventer, at man er en seriøs studerende, mens man er på UCSD. Hvis du skal læse mere end én Session på UCSD og får academic probation efter den første pga. en eller flere B- (eller lavere) karakterer, betyder det, at du skal have en samtale med Megan Schuck ang. hvilke fag, du kan få lov til at tage i den følgende Session. Det betyder altså ikke, at du ikke må fortsætte på næste Session, men der vil være risktriktioner i forhold til de fag, du må tage. Hvis du er i tvivl om ét eller flere af punkterne, er du velkommen til at spørge EDU. Du skal sende det udfyldte ansøgningsskema samt følgende dokumenter til EDU: En udfyldt ansøgningserklæring. Erklæringen finder du på UCSDs profil på vores hjemmeside under punktet 'Hvordan søger jeg?' > 'Sådan søger du' Karakterudskrift på engelsk fra din nuværende uddannelse. Du skal dokumentere de sidste to års/fire semestres afsluttede studier. Såfremt du ikke har afsluttet fire semestre på din nuværende uddannelse, kan du vedlægge karaktererbevis på engelsk fra en evt. tidligere uddannelse eller din gymnasiale uddannelse (original eller verificeret vejledning@edu-danmark.dk Senest opdateret 8-Aug-14

5 kopi). Bachelorbevis på engelsk, hvis du allerede har afsluttet en bacheloruddannelse (original eller verificeret kopi). En udfyldt UPS Course List Form med minimum 12 fag du kunne tænke dig at følge på universitetet pr. Quarter (du skal skrive minimum 12 fag på listen) Dokumentation fra din bank på, at du kan dække omkostningerne til dit ophold (udfyldt Financial Verification del (A4) eller separat bankbrev) Kopi af dit pas (billedsiden, behøver ikke verificeres) Motivationsbeskrivelse på højst 1 side, hvor du forklarer, hvorfor du ønsker at læse på universitetet, samt hvilke ikke-akademiske aktiviteter, du ønsker at deltage i under dit studieophold (på engelsk) Evt. dokumentation for engelskkundskaber.* Medical Insurance Verification Form (side A5) - eftersendes efter optagelse Tuberculosis Screening Questionnaire (side A6) - sendes med eller eftersendes Acknowledgement Form * NB! Hvis du er dansk statsborger og har taget hele din uddannelse (inklusiv folkeskole og gymnasium) i Danmark, behøver du ikke at dokumentere dine engelskundskaber, når du søger ind på UCSD. Hvis du er dansk statsborger, men ikke er født i Danmark, skal du sende både dit folkeskolebevis og dit gymnasiebevis sammen med din ansøgning. Hvis du ikke er dansk statsborger, men gerne vil søge ind på UCSD, så kontakt vejledning@edu-danmark.dk. Alle dokumenter (som ikke er lavet af dig selv) skal være stemplet og underskrevet med mindre andet er anført. Originale dokumenter eller verificerede kopier skal sendes til EDU sammen med dit ansøgningsskema. Du får dine originale dokumenter tilbage sammen med en bekræftelse på, at du har søgt optagelse på University of California San Diego. Ansøgningen sendes til: EDU Nikolaj Plads 26, København K Ved spørgsmål kan du kontakte os på vejledning@edu-danmark.dk vejledning@edu-danmark.dk Senest opdateret 8-Aug-14

6 How to Apply UC San Diego Extension International Programs 2016 The following items must be enclosed with your application. All documents must be in English. 1. For all programs, these items must accompany the application: A Application fee (nonrefundable for each program) English Language Programs: $150 Academic Connections International: $200 University Credit and Summer Session Programs: $200 Certificate Programs: $200 B C Copy of passport name-page Financial verification OR copy of bank statement WITH SPONSOR S SIGNATURE IN SECTION 4 OF PAGE A4 IF I-20 IS REQUIRED. D Express mail fee, optional but strongly recommended: $50 (may vary depending on location) E F Information Release form for those students who have financial sponsors or who enroll in our programs through a university partnership agreement. Please request the Information Release form from ipinfo@ucsd.edu. Transfer students must submit the UC San Diego Extension International Programs Academic Verification Form along with the application to be considered for transfer. Students may request this form from ipadmission@ucsd.edu. G On-campus housing application, if desired: Include the on-campus housing application found on our website under Student Life. Full payment must be included with the on-campus housing application to reserve a space. (See page 28.) H For all programs, we must receive the following at least 30 days before the published program start date: 1. Payment for UC San Diego medical insurance or Medical Insurance Verification Form completed by insurance provider, plus proof of coverage benefits on insurance company letterhead. (See page A5.) 2. Tuberculosis Assessment Form. (See page A6.) 3. Proof of required vaccinations. See information with program acceptance material. 4. Full payment of tuition and fees as invoiced by us after acceptance is sent. Note: For applications received fewer than eight weeks before the program start date, all payments and documents listed in H1-4. (above) must be submitted along with the application. 2. For English language programs and seminars: Intensive Legal English program: Applicants must submit academic transcripts for the four most recent semesters of study, showing some previous coursework in Western law or Western civilization, and a brief statement to explain previous law-related experience and their purpose in taking this program. Applicants must have advanced English proficiency. All students must take the UCSD-ELI placement tests upon arrival. However, a score of 90 on the TOEFL ibt or 7.5 on the IELTS will fully satisfy the required proof of advanced English proficiency. For our University Preparation Academy, students must submit the following items: High school or university transcripts for the four most recent semesters must show grades in the top 5-10%. Transcripts must be in English. New students must have a language proficiency score of 90 ibt or 7.5 IELTS. Continuing students coming directly from UC San Diego s ELI 10-week programs must have excellent attendance and grades in previous ELI classes, placement in one of ELI s highest proficiency levels, and certain minimum scores on ELI s placement exams. (Specific requirements for continuing students are available from the ELI Academic Advisor.) 3. For TEFL Certificate programs: Language proficiency verification Copy of transcripts in English for the two most recent years of academic studies A one-page statement explaining why you would like to take the TEFL Certificate program, the Special Studies in TEFL program, or the TEFL Proficiency program. 4. For University and Professional Studies (UPS): Language proficiency verification Copy of transcripts in English for the TWO most recent years (four semesters) of academic studies. These transcripts must clearly indicate excellent academic achievement, including cumulative grade point average. List of 12 or more courses per quarter using our Course List Form, organized by quarter, which you would like to take at UC San Diego or UC San Diego Extension. You will find our Course List Form on our website under What to Send in our How to Enroll section. A one-page statement explaining your reasons for choosing UC San Diego for your study abroad experience. 5. For Business Certificate Programs: Please see pages of the brochure for admission requirements. For the Business Management program, please indicate the program specialization on the application form. For the business programs, it is recommended to submit the application four months in advance. Not all applicants are admitted to the programs. Space is limited and the admissions review is competitive. 6. For Academic Connections International (ACI) and Summer Session: Please see website in April 2016 for details and for the supplemental application: ip.extension.ucsd.edu If possible, please send page A3 of the application and all supporting documents as one pdf file to ipadmission@ucsd.edu. To protect your credit card information, please send page A4 of the application to our secure fax number: A1

7 Frequently Asked Questions A) Do I need to arrive on time for my program to complete registration? Yes, you must arrive at least one day before the published program start-date. Students who do not complete all required registration items by 4 p.m. on the first published start-date of the program must pay a Late Registration fee of $200 USD. B) Do I need a student visa (F-1) to attend your programs? If your main intent in coming to the U.S. is to study, you should apply for a student visa. If you are coming to the U.S. mainly for tourism, and you also want to take English classes for your own pleasure or as recreation, then a tourist visa (B-2) or Visa Waiver (WT) is appropriate. If you are not sure whether study or tourism is your main intent, explain your plans to the U.S. Embassy or Consulate in your country and they will advise you on the appropriate visa to apply for. You should not schedule a visa interview until you have received our acceptance letter and other acceptance materials. COST CALCULATOR C) How much money do I need to study and live in the U.S.? You can calculate your total estimated expenses by using the following chart: Program length Tuition (fill in amount) Living expenses* Other costs** Total 4-week ESL Program $ $ 1,500 $ 570 $ 10-week ESL Program $ $ 3,600 $ 1,340 $ UPS (1 quarter) $ 7,800 $ 3,675 $ 1,590 $ 13,065 Certificate Program (1 quarter) $ $ 3,900 $ 1,430 $ Certificate Program (2 quarters) $ $ 7,500 $ 2,755 $ Certificate Program (3 quarters) $ $ 12,150 $ 3,420 $ Certificate Program (4 quarters) $ $14,700 $ 4,495 $ 5-week Summer Session Full-time $ $ 1,800 $ 1,075 $ *Living expenses include: housing, utilities, food, and incidentals, such as clothing and entertainment. **Other costs include: international student service fee, health insurance, books, supplies, school ID and library cards, and transportation, as described in the Additional Costs page of our brochure. Please note that the living expenses and other costs listed above are estimates and vary depending on individual housing choices. If you plan to bring your spouse and/or children, your financial verification must include an additional $500 per month for your spouse and $300 per month for each child. D) How long will it take to receive my acceptance information? We will mail your acceptance information as soon as possible after we receive your complete application with all required documents and fees. During peak times, it can take several weeks before acceptance documents are sent. For fast delivery, we recommend you choose the express mail option see Payment Procedure in the application. Applications without express mail take an average of weeks for delivery. E) How do I apply for housing? Refer to our brochure or the student life tab on our website for information on housing options. When you are ready to apply, contact the individual housing vendors for their application and additional information. F) What method of payment do I use? Application and express mail fees must be paid by credit card. For all other fees, please enclose a money order or bank draft in U.S. dollars, payable to UC Regents. A bank draft must be drawn on a U.S. bank or a U.S. branch office of your bank. We cannot accept Eurochecks. We cannot accept electronic transfers (ACH). You may also pay by credit card or bank-to-bank transfers via Western Union Business Solutions. Western Union Business Solutions offers a competitive rate of exchange for processing payments in many international currencies. For more information about this method of payment please ipfinancials@ucsd.edu. If paying by credit card, please do not send your credit card number to us by . Please only send your credit card number to our secure fax number: G) Am I required to purchase UC San Diego medical insurance? You are not required to purchase UC San Diego medical insurance. However, you are required to have medical insurance in order to study on campus. If you choose not to purchase UC San Diego medical insurance, your insurance company must provide proof of medical insurance that will provide the five minimum coverage amounts listed in section 3 of page A5 of this application for the total duration of your studies at UC San Diego Extension International Programs. If you choose to purchase your own medical insurance, your insurance company must fill out the Medical Insurance Verification form located on page A5. For more information, please our Student Health and Welfare Advisor at iphealth@ucsd.edu. H) Why do I have to provide the Tuberculosis (TB) Form? Because of the increasing occurrence of Tuberculosis (TB) around the world, and because people travel more frequently, UC San Diego requires all domestic and international students to confirm their TB status if they have lived in or traveled to regions which are listed as high frequency for TB cases by the U.S. Centers for Disease Control (CDC). A2

8 UC UC San Diego Extension International Programs Personal Information (Please print very CLEARLY and read instructions on page A1. Incomplete applications will not be processed, Medical Insurance Verification Form and will be sent back to the student or agent. PLEASE NOTE: Hanmail, Daum, and Naver accounts are blocked by UC San Diego .) Are you buying UC San Diego medical insurance? Yes. If yes, do not fill out this form. Country of Birth Date of Birth month/day/year (e.g. JAN 01, 1979) No. If no, your insurance company must complete and submit this form at least 30 days before your program start-date. All information fields are required. Family Name (surname) (ATTACH COPY OF PASSPORT NAME-PAGE) First Name (given name) (as it appears in your passport) Male Female Country of Citizenship Student s (Please print clearly.) Agent s Please attach a summary of benefits in English on company letterhead from your medical insurance company to prove coverage Native Language for the five required minimum benefits listed in section 3 below. PLEASE NOTE: Hanmail, Daum, and Naver accounts are blocked by UC San Diego . I will pick up my acceptance information from the UC San Diego Extension Please Student s submit permanent the address completed in home Medical country (required): Insurance Verification Form by fax or to or iphealth@ucsd.edu. Check here if this is where you want your I-20 and acceptance materials office, Bldg E, OR 1. Student Information: to be mailed. Address to which I-20 and acceptance materials should be mailed: Family Address Name Street Apartment Number First Student Name Name or Agency Name Student s Address (continued) Date Address of Birth month/day/year (e.g. JAN Street 01, 1979) Apartment Number 2. City Medical Insurance Postal Company Code Information: Country City Postal Code Country Company Telephone Name (country code/city code/number) Policy Telephone Number (country code/city code/number) Fax (country code/city code/number) 2. Program Information I am applying to the following program(s) (check all that apply and indicate start-date for each): Date insured from month/day/year (e.g. JAN 01, 1979) Date insured to month/day/year (e.g. JAN 01, 1979) Important I plan to Note: enroll Dates for: of insured coverage must include the entire length University of the Credit student s Programs program at UCSD. Start Date 1 session 2 sessions 3 sessions Summer Session Full-time 3. Insurance 4 sessions Coverage not sure Amounts (to be completed by insurance Summer company Session only) Part-time* All 5 items must equal or exceed UC San Diego Required Minimum Benefits. UC San Diego medical Note: insurance For Academic requirements Connections include International full coverage for Summer pre-existing Session, conditions and mental Ten-week health. Please English find an Language insurance plan Programs which covers ALL pre-existing Start Date conditions and mental obtain health Supplemental (without any restrictions). Application from our website. Communication and Culture Intensive Communication and Culture Certificate Programs Enter Below: insurance coverage in equivalent UC San Diego Medical Insurance provides UC San Intensive Diego Academic Required English Minimum Benefits Business Management U.S. (2 quarters) dollars (must equal or exceed UC San Diego the following benefits: Required Minimum Benefits) Intensive Business English Student must choose specialization: 1. $250,000 Intensive USD Legal per English illness or injury, including 1. Unlimited per illness or injury, including Finance Global 1. Commerce $ Human per illness Resources or injury, Marketing including pre-existing Intensive and TOEFL mental Preparation health conditions (all illnesses pre-existing conditions and mental Business health Management pre-existing (3 quarters) conditions and minor illnesses and injuries and injuries, not just emergencies and accidents) University Preparation Academy Student must choose specialization: 2. $50,000 Other Finance Global Commerce Human Resources Marketing USD for medical evacuation 2. $50,000 USD medical evacuation 2. $ for medical evacuation Project Management (2 quarters) 3. Short-term $25,000 USD for English repatriation Programs of remains and Seminars 3. $25,000 USD repatriation of Intermediate remains Business 3. Essentials $ (1 quarter) for repatriation of remains Conversation (45 hours)* Intermediate Business Essentials (2 quarters) 4. A deductible Conversation not and to exceed Fluency $75 (80 USD hours) per 4. $75 USD deductible per illness Intermediate or injury Business 4. Essentials $ (3 quarters) deductible per illness/injury illness Business or injuryenglish Business Essentials (1 quarter) Academic English % coverage of all medical care and 50% coverage % coverage for all medical Business care and Essentials 50% (25. quarters) Coverage by our company is at % after of prescribed Medical medicines English after the deductible for prescribed medications after Business deductible Essentials (3 the quarters) deductible, including % coverage for prescribed quarters) medicines Other Business Essentials (4 Medical University insurance Credit company Programs payment procedure (check one): Start Date TEFL (6-month) Summer Intensive TEFL University Student and pays Professional medical fees Studies and is later reimbursed by the medical insurance company. Special Studies in TEFL Academic Insurance Connections company is International* billed directly. TEFL Proficiency Other, please explain: Other Official Stamp of Medical *This program does not qualify for an I-20. Required: Insurance Company 1) Official Stamp from your medical insurance company Have you to confirm attended above any coverage of our and programs dates. before? If so, when? 2) English-speaking claims representative in your insurance company: 3. Transfer Students Name Will you be coming directly from another school in the U.S.? No. If no, we need no further information regarding your transfer status. Phone Yes. If yes, you must submit the UC San Diego Extension International Programs Academic Verification Form along with the application to be considered for transfer. Address Street Apartment Number Students must download the Academic Verification Form from the How to Enroll section of the ip.extension.ucsd.edu webpage or request it from ipinfo@ucsd.edu. City Postal Code Country Current of English-speaking school name representative in insurance company (Please print Telephone clearly.) Dates of attendance A3A5

9 4. I-20 Request Student s FAMILY name (surname) FIRST name (given name) Do you need an I-20? YES. If yes, please select one: for an F-1 visa for school transfer for change of status NO, I do not need an I-20. I am (please check one): U.S. Citizen/Permanent Resident Other non-immigrant status (specify) Financial Verification Please check source of your funds: Personal/Own Family Other (specify) A. REQUIRED FOR I-20: A bank statement or signed letter of sponsorship in English by an approved company or school, dated within the last 90 days and showing enough funds for the first program which the student is applying to, plus living expenses and other costs. Please see expense calculator chart on page A2 of the application form to determine total funds needed. If the bank statement is in a foreign currency, it must show enough funds when converted to U.S. dollars. Name of account holder Bank location (city and country) Name of bank Official Bank Seal/ Stamp Amount of available funds in equivalent U.S. dollars (must equal or exceed amount needed in section C on page A2) Date (within last 90 days) Name and Title of Bank Official Signature of Bank Official B. REQUIRED FOR I-20: The family member or other person who is financially responsible for you must read this statement and sign below. I have read the information regarding the cost of tuition and living expenses and other costs for the period of study at UC San Diego, Extension. I certify that these funds are available, and I accept full responsibility for these expenses. Name of person financially responsible (print clearly) Signature Relationship to student Date (m/d/y) Dependents If you plan to bring your spouse (wife or husband) and/or children on F-2 visas, you must list them here. Attach additional sheet if more space is needed. Please include copy of passport name-page for each family member. (Parents and siblings are not considered dependents.) Family name Given name Birthday (e.g., JAN 01,1997) Country of birth/country of citizenship Relationship to you Male Female Family name Given name Birthday (e.g., JAN 01,1997) Country of birth/country of citizenship Relationship to you Male Female Do any of your family members plan to study full-time at UC San Diego? Yes No 5. Payment Procedure You must submit the non-refundable application fee and express mail fee, if selected, with your application. Application fee/express mail fee must be paid by credit card. All other fees must be paid in full 30 days before your program, or you may include full or partial payment now. Payment for the UC San Diego photo ID card and for textbooks CANNOT be made in advance and can only be purchased after arrival at UC San Diego. Please indicate the amount you are enclosing with this application: English Language Programs application fee: $150 Academic Connections International application fee: $200 University Credit Programs application fee: $200 Certificate Programs application fee: $200 Partial or full tuition amount (ESL programs only): $ International Student Services fee (see pg. 27 for details): $ 3-day express mail delivery of I-20 due with application: $50 (Strongly recommended because regular airmail can take weeks for delivery. Fee may vary depending on location.) Medical insurance from UC San Diego (if selected, see pg. 27 for cost): $ Program change fee: $150 TOTAL amount enclosed with this application: $ PAYMENT OPTIONS (Please do not mail cash or traveler s checks.) I have enclosed a money order/bank draft in the amount of $ (Make checks payable to UC Regents. All checks must be drawn from U.S. banks.) I would like to pay by credit card. If paying by credit card, write your full name at the top of this page and send it to our secure fax. Do not send your credit card number by . MasterCard Visa AMEX Diners Club Discover $ Credit card number Expiration date (month/year) Total to be charged Name on credit card Authorized card holder s signature 6. Signature (Application cannot be processed without a student signature.) I certify that all application information is true and that I have read and understand the policies described in this application and the Extension International Programs brochure. I acknowledge that I am required to pay the non-refundable application fee even if I decide to withdraw or cancel my enrollment. Signature of applicant Date REFERRING AGENCY/UNIVERSITY (REQUIRED TO DOCUMENT STUDENT REFERRAL) Please fax, express mail, or completed application and required documents to: Express Delivery Address: University of California, San Diego Extension International Student Services 9600 N. Torrey Pines Road, Bldg. E La Jolla, CA Fax: ipadmission@ucsd.edu Agency/University name Contact name Fax A4

10 UC San Diego Extension International Programs Personal Information (Please print very CLEARLY and read instructions on page A1. Incomplete applications will not be processed, Medical Insurance Verification Form and will be sent back to the student or agent. PLEASE NOTE: Hanmail, Daum, and Naver accounts are blocked by UC San Diego .) Are you buying UC San Diego medical insurance? Yes. If yes, do not fill out this form. No. If no, your insurance company must complete and submit this form at least 30 days before your program start-date. All information fields are required. Family Name (surname) (ATTACH COPY OF PASSPORT NAME-PAGE) First Name (given name) (as it appears in your passport) Male Female Country of Birth Date of Birth month/day/year (e.g. JAN 01, 1979) Country of Citizenship Student s (Please print clearly.) Agent s Please attach a summary of benefits in English on company letterhead from your medical insurance company to prove coverage for the five required minimum benefits listed in section 3 below. PLEASE NOTE: Hanmail, Daum, and Naver accounts are blocked by UC San Diego . Native Language I will pick up my acceptance information from the UC San Diego Extension Please submit the completed Medical Insurance Verification Form by fax or to or iphealth@ucsd.edu. office, Bldg E, OR 1. Student Information: Student s permanent address in home country (required): Check here if this is where you want your I-20 and acceptance materials to be mailed. Address to which I-20 and acceptance materials should be mailed: Address Family Name Street Apartment Number Student First Name Name or Agency Name Address Student s (continued) Address Date of Birth month/day/year (e.g. Street JAN 01, 1979) Apartment Number 2. Medical Insurance Company Information: City Postal Code Country City Postal Code Country Telephone Company (country Name code/city code/number) Telephone Policy Number (country code/city code/number) Fax (country code/city code/number) 2. Program Information I am applying to the following program(s) (check all that apply and indicate start-date for each): Date insured from month/day/year (e.g. JAN 01, 1979) Date insured to month/day/year (e.g. JAN 01, 1979) I Important plan to enroll Note: for: Dates of insured coverage must include the entire University length of Credit the student s Programs program at UCSD. Start Date 1 session 2 sessions 3 sessions Summer Session Full-time 3. 4 sessions Insurance Coverage not sure Amounts (to be completed by insurance Summer company Session Part-time* only) All 5 items must equal or exceed UC San Diego Required Minimum Benefits. UC San Diego medical Note: For insurance Academic requirements Connections include International full coverage or Summer for pre-existing Session, conditions and Ten-week mental health. English Please find Language insurance Programs plan which covers ALL Start pre-existing Date conditions and mental obtain health Supplemental (without Application any restrictions). from our website. Communication and Culture Intensive Communication and Culture Certificate Programs Enter Below: insurance coverage in equivalent UC San Diego Medical Insurance provides UC Intensive San Diego Academic Required English Minimum Benefits Business Management (2 U.S. quarters) dollars (must equal or exceed UC San Diego the following benefits: Required Minimum Benefits) Intensive Business English Student must choose specialization: 1. Intensive $250,000 Legal USD English per illness or injury, including 1. Unlimited per illness or injury, including Finance Global Commerce 1. $ Human per Resources illness or injury, Marketing including pre-existing Intensive TOEFL and mental Preparation health conditions (all illnesses pre-existing conditions and mental Business health Management (3 pre-existing quarters) conditions and minor illnesses and injuries and injuries, not just emergencies and accidents) University Preparation Academy Student must choose specialization: 2. Other Finance Global Commerce Human Resources Marketing $50,000 USD for medical evacuation 2. $50,000 USD medical evacuation 2. $ for medical evacuation Project Management (2 quarters) Short-term 3. $25,000 USD English for repatriation Programs of remains and Seminars 3. $25,000 USD repatriation Intermediate of remains Business Essentials 3. $ (1 quarter) for repatriation of remains Conversation (45 hours)* Intermediate Business Essentials (2 quarters) 4. Conversation A deductible and not Fluency to exceed (80 $75 hours) USD per 4. $75 USD deductible per illness Intermediate or injury Business Essentials 4. $ (3 quarters) deductible per illness/injury illness Business or injury English Business Essentials (1 quarter) Academic English % coverage of all medical care and 50% coverage % coverage for all medical Business care Essentials and 50% (2 quarters) 5. Coverage by our company is at % after of Medical prescribed English medicines after the deductible for prescribed medications Business after deductible Essentials (3 quarters) the deductible, including % coverage for prescribed medicines Other Business Essentials (4 quarters) University Medical insurance Credit company Programs payment procedure (check one): Start Date TEFL (6-month) Summer Intensive TEFL University Student and Professional pays medical Studies fees and is later reimbursed by the medical insurance company. Special Studies in TEFL Academic Insurance Connections company International* is billed directly. TEFL Proficiency Other, please explain: Other Official Stamp of Medical *This program does not qualify for an I-20. Required: Insurance Company 1) Official Stamp from your medical insurance Have company you to attended confirm above any of coverage our programs and dates. before? If so, when? 2) English-speaking claims representative in your insurance company: 3. Transfer Students Will Name you be coming directly from another school in the U.S.? No. If no, we need no further information regarding your transfer status. Phone Yes. If yes, you must submit the UC San Diego Extension International Programs Academic Verification Form along with the application to be considered for transfer. Address Street Apartment Number Students must download the Academic Verification Form from the How to Enroll section of the ip.extension.ucsd.edu webpage or request it from ipinfo@ucsd.edu. City Postal Code Country Current of English-speaking school name representative in insurance company (Please Telephone print clearly.) Dates of attendance A5 A3

11 UC San Diego Extension International Programs 2016 Tuberculosis (TB) Questionnaire Because global travel for business, studies, and pleasure has increased, the risk of TB exposure has also increased. For everyone s health and safety, all visitors and students must complete and return this form at least 30 days before the program start-date. Family name of participant First name of participant Date of birth Student Address Please answer the following questions: Have you ever had a positive TB skin or blood test? Yes No Have you ever had close contact with anyone who was sick with TB? Yes No Are you from or have you ever lived or traveled in one of the following areas: Mexico, South or Central America, Eastern Europe, Asia, the Middle East, or Africa? Yes No If all questions are answered NO, you have completed your TB Assessment. Please send the TB Questionnaire to iphealth@ucsd.edu or fax it at After you submit the TB Questionnaire, there is nothing more for you to do regarding the TB Assessment. If any questions are answered YES, then you must also have your health care provider complete the TB Assessment below, documenting either treatment for TB or negative TB test results thirty (30) days before the start of your program. Tuberculosis (TB) Assessment This part of the form must be completed only by a licensed health care provider. The completed, signed form must be faxed to UC San Diego Extension International Student Services at Or it can be sent to us as a scanned document attached to an sent to: iphealth@ucsd.edu. RISK FACTORS: (please ask student and check any that apply) 1. Immunosuppressed (HIV/AIDS), organ transplant, or on immunosuppressant medication Yes No 2. History of abnormal chest x-ray suggestive of TB disease Yes No 3. Does the student have signs or symptoms of active tuberculosis disease? Yes No (Cough more than 3 weeks, chest pain, unexplained weight loss, fevers, night sweats) If no, proceed to 4 or 5. If yes, proceed with additional evaluation to exclude active TB, including TB skin or blood testing, chest x-ray, and sputum evaluation as indicated, and show results below. 4. Tuberculin Skin Test (TST) TST results should be recorded as millimeters (mm) of induration. If no induration, write 0. Five mm is considered positive if there is a history of abnormal chest x-ray, recent exposure to active TB disease, or is immunosuppressed. 10 mm induration is considered positive if coming from a high-risk area or has other high-risk conditions (IV drug use, chronic renal disease, cancer, diabetes, malabsorption or GI bypass). Date TST test was given: Date TST test was read: Result: Interpretation: negative positive mm induration 5. TB Blood Test (Interferon Gamma Release Assay-IGRA) (The TB blood test may be done instead of TST. Strongly recommended if there is a history of positive TST or BCG vaccination.) 6. Chest X-Ray (required if TST or IGRA is positive) Date of chest x-ray: Result: normal abnormal (including scars, and old granulomatous changes) If chest x-ray is abnormal, please submit the following results. Sputum Results (AFB and culture x 3 required if chest x-ray abnormal): #1 Date AFB Culture #2 Date AFB Culture #3 Date AFB Culture 7. Treatment for Latent TB (if applicable): Medication(s) Start date: Date obtained: Result: negative positive intermediate Completion date: Licensed Healthcare Provider s Name (please print in block letters): Healthcare Provider s signature: Healthcare Provider s stamp: Date: A6 A6

12 INTERNATIONAL STUDENT SERVICES GILMAN DRIVE UCSD EXTENSION, 0176-D website: ip.extension.ucsd.edu LA JOLLA, CALIFORNIA tel: fax: Dear UPS Applicant: Thank you for applying to the University and Professional Studies Program (UPS) at UCSD. Before we can process your application for admission to the UPS program, you must indicate that you understand and accept ALL of the items listed below. Please put your initials after each statement to indicate that you understand and agree to these terms of enrollment and fax it back to us at (858) or it to Attn: Megan Schuck, UPS Advisor. I understand and agree that: Acceptance into the UPS program does not guarantee enrollment into any specific class or course of study. UPS students are not guaranteed enrollment in any class. Matriculated UCSD undergraduate and graduate students get priority enrollment in UCSD classes. Class enrollment for UCSD Extension s UPS students is on a space-available basis. Class enrollment for UPS students requires instructor/departmental approval. There is no pre-enrollment in UCSD classes for UPS students. In other words, UPS students cannot seek instructor/departmental approval until the first day of UCSD classes each quarter, and most UCSD departments do not start admitting visiting students until after the second week. I will attend courses in the first two weeks of each quarter to ensure access to a full-time load of classes (12 units, usually 3 courses) as required by UCSD Extension policy and U.S. immigration law for students who enter the U.S. on the F-1 student visa. Departmental approval for Biology, Chemistry, Economics, Rady School of Management, History, Political Science, and Psychology classes will not be given until the third week of classes each quarter. UPS students may not enroll in any UCSD Extension Business Department courses including business, law, and leadership and management. UPS students are not eligible to enroll in graduate-level courses at the Rady School of Management. I will provide documentation of TB status and proof of medical insurance which meets UCSD Extension s requirements before starting classes at the University of California, San Diego. I will achieve final grades of A or B in all of my classes. I will be placed on academic probation if I receive a final grade of B- or below in any class. I acknowledge that if I receive a B- or below while on academic probation I will not be able to continue in the UPS program. UPS students will receive a certificate if all of their grades are A or B. UPS students who receive a final grade of B- or below in any class will not receive a certificate. My initials above indicate that I understand and accept each of the statements above. Signature Printed name (please write last name in CAPITAL LETTERS) Date (month-day-year)