Biographical Data and Visa Information

Application Form--PDF (You need Adobe Acrobat Reader to read PDF files. You may download it here.)

1. Program Information

Please clearly indicate the program(s) to which you would like to apply.

International Diploma Programs

Business Administration (BA)
Computer Information Systems (CIS)
E-Commerce Business & Technology (EC)
Finance (FI)
Information Technology Management (ITM)
International Business & Management (ITC)
Marketing (MK)
Project Management (PM)
System & Network Administration (SNA)
Term for which you are applying:

January May September
YEAR:_________________________

2. Personal Information

Please type or print clearly. Print name as it appears on passport.

Family name
First name (given name)
Male Female

Date of birth
month day year


Country of birth
Country of citizenship
Permanent Address in Home Country (mandatory):

Street
City and Postal Code
Country
Permanent telephone
Fax
E-mail



U.S. Social Security number (Mandatory if you are in possession of one. Lack of one will not affect the processing of your application.) The University is required by federal law to report your Social Security number (SSN) and other pertinent information to the Internal Revenue Service pursuant to the reporting requirements imposed by the Taxpayer Relief Act of 1997. The University will also use the SSN you provide to verify your identity. SSN disclosure is mandatory. This notification is provided to you as required by the Federal Privacy Act of 1974.

IMPORTANT NOTE: In order for you to receive your form 1-20, a street address is required. Your 1-20 document cannot be delivered to a P.O. box.

Street Address to which 1-20 Should Be Sent (if different from permanent address):

Street
City and Postal Code
Country
Phone
Fax
E-mail

3. Where Did You Hear about Our Programs?

Friend Relative Employer Internet
Education Fair International Representative (please indicate representative's name below)
Other (Please describe):

4. Dependents Traveling with You to the United States

Name (family name, first name)
Date of Birth (month/day/year)
Citizenship
Relationship
Name (family name, first name)
Date of Birth (month/day/year)
Citizenship
Relationship

5. Fee To Be Submitted with This Application


International Diploma Program $100
Please enclose a money order or bank draft in U.S. dollars, payable to UC Regents, for the corresponding amount. The draft must be drawn on an account held at an American bank or a U.S. branch of an international bank. Fees may also be charged to one of the following credit cards:

MasterCard Visa American Express
Account number
Date card expires
Authorized signature

6. Visa Information

Will you have entered the U.S. (prior to receiving our visa document) and be remaining here until such time as the semester begins?
Yes
If yes, please submit copies of your passport, visa, I-94, and I-20, if applicable.
No
If no, please skip to Section 8.

When will your passport expire? (month/day/year)
When will your I-94 expire? (month/day/year)
(Your I-94 is the small white card you were given at the port of entry.)

Please list your I-94 number
What visa status were you given at the port of entry?

F-1 (F-1 students please also complete Section 7)

B-1

B-2

Other Explain below


7. F-1 Student Visa Transfer Process

From what other U.S. educational institution or program will you will be transferring to UC Berkeley Extension? ELP-Berkeley ELP-San Francisco Other

Other school's name
Month/day/year of your last date of attendance
International student advisor's name
Phone
Fax

8. Proof of English Language Proficiency

For the issuance of Form I-20, sufficient English proficiency must be both displayed and documented. Please indicate below the manner of documentation you will be submitting with your application.

I have directed Educational Testing Services (ETS) to send my TOEFL score report directly to UC Berkeley Extension. (Please remember to indicate our ETS institution code: 9216.)

I am enclosing my TOEFL score report of at least 213 (550 paper-based).

I am enclosing my TOEIC score report of at least 760.

I am enclosing my IELTS score report of at least 6.5.

I am enclosing my Cambridge Certificate of Advanced English or a copy of my Cambridge Proficiency Exam score report.

I am a citizen of an English-speaking country. Enclosed please find a copy of my passport.

I have earned a degree from a university in an English-speaking country. The medium of instruction was exclusively English. Enclosed please find my transcripts.

9. Applicant Signature

I hereby certify that the foregoing and all information referenced in or enclosed with this application is to the best of my knowledge true and correct.

Applicant Signature

Date



Please send this application form and enclosures to:
    International Student Services
    UC Berkeley Extension
    1995 University Avenue
    Berkeley, CA 94720-7003
    USA

    Before mailing the application, please be sure that you are including the following:


    In order to be considered for admission, you must include all pages of the application.