Application form: Outbound Exchange student

Outbound International student exchange / Study abroad application form

Academic year 2015
Section A: Applicant details
Full Name*

First NameMiddle NameLast Name
RSU student ID number
Major Field of study*
Faculty
Year of study*
Current Grade point average*
E-mail*
Phone Number*

Country codeArea code + Phone number
Facebook (if any)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

DayMonthYear
Gender*
Country of Citizenship*
Passport number
Scan of Student Card*

Upload a File

Cancelof
Section B: Exchange program details

At partner university
Apply for exchange program at
Please specify the second and third choice of your preferred host university:
Specify exchange period
Proposed field of study (Program, Faculty)
Proposed study plan
Please describe your motivations to participate in exchange program (No entry limit)*
Please describe why you should be nominated as the exchange student
Interests / Hobbies
Is English your first language?

If "No" please provide information on your English language proficiency*

	Very good	Good	Fair	Poor
Speaking
Listening
Reading
Writing

English language proficiency test score (if available)
Transcript / Study record*

Upload a File
Upload scan of original transcript / study record issued by Registrar office of the home institution Cancelof
English language proficiency certificate

Upload a File
Upload scan of original transcript / study record issued by Registrar office of the home institution Cancelof

Section C: Emergency contact
Full Name*

PrefixFirst NameMiddle NameLast Name
Relationship*
E-mail*
Phone Number*

Country codePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Section D: Reference
Name of Referee*

PrefixFirst NameMiddle NameLast Name
Title
Faculty / Office
E-mail
Phone number
Reference form

Upload a File
Please download institutional nomination form signed and sealed by authorized person at the home institution Cancelof
Section E: Medical and further information
D1: Any disabilities and/or medical condition that RSU CIEL should be aware of?

YesNo
If "Yes" (D1), please explain
D2: Have you ever been convicted of a criminal crime offense?

YesNo
If "Yes" (D2), please explain
3: Do you foresee any other difficulty that may affect the completion of your exchange period?

YesNo
If "Yes" (D3), please explain
CHECKLIST

Have you uploaded the scanned of the following documents;

: : scan of student ID card

: : scan of transcript / study record

: : nomination form signed by the Advisor and Faculty International Coordiantor or Associate Dean for International Affairs

**This application will not be processed unless it is complete and is accompanied by the above listed documents.
APPLICANT'S DECLARATION

By submitting this online Exchange application form, I certify that the statement made by me are true, complete, and correct to the best of my knowledge. I fully understand if I am to join the program, I agree to;

1. follow thw course of study and abide by the rules of Rangsit Universityand the law of Thailand;

2. act in such a manner that I will not bring disrepute to myself, Rangsit University, host institution or my country of citizenship during the Exchange program;

3. abide by the rules and regulations governing my visa;

4. release information contained in this application form to relevant authorities and for RSU VIE exchange student yearbook/semesterbook publication;

5. responsible for any study materials, personal and medical expenses that shall incur during my exchange period at Rangsit University;

6. obtain full international travel and health insueance prior to the departure to Thailand;

7. the use of photographs of myself taken by CIEL, Rangsit University - the likely uses include promotional materials, brochures, displays, expos, posters, cards, newspaper article, website, communication with eductional agents and advertising.

8. the terms and agreements as per the Memorandum of understanding established in regard to exchange activtity between the host institution and Rangsit University
Date and time of submission

MonthDayYearHourMinutesAM/PM Option
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