*First Name:

*Last Name:

Middle Name:

*Student ID Number:

*Email Address:

*Phone:

Program:

Select Exchange Program... National Student Exchange Program (NSE) Student Exchange Program (ISEP) Northwest Council on Study Abroad (NCSA) University of Lulea, Sweden Other/Unknown

Proposed Dates of Exchange or Study Abroad

to

Faculty Advisor:

Current Address:

Permanent Address:

City:

State:

Zip Code:

*Class Status:

Freshman Sophomore Junior Senior Select

UAS Degree and Major:

*Expected Grad. Date:

*Cumulative GPA:

Financial Aid (Planned/Current):

Special Needs (Diet, Health, etc.):

Foreign Language Training:

Other Comments/Questions: