SIUC International Template

International Student Information Request Form

Name

Last (Jr, II, III, IV, etc)

First Middle Name

Salutation

Social
Security No.

(You may leave this blank if you do not have a social security number.)

Date of Birth (month/day/year - mm/dd/ccyy)

Address

Number and Street

City State

ZIP Code

Country

Phone
(country-area code-number, ###- ###-###-####)

If in Illinois, what county:

E-mail
Fax

E-mail Address:

Fax Number:
(country-area code-number, ###- ###-###-####)

Educational
Information

I'm thinking about attending SIUC as a

I'd like to start in

I have the following academic interests:

I currently attend this school:

1Information
Requests

Please send me more information about: