Important you must use the Print and Submit button at the bottom of the page and send the hard copy to the address below.
Last Name: First: Middle:
SS#: ________________ Passport #: __________________ Student ID #:
Date of Birth: Male Female
Current Mailing Address: Phone:
City: Email:
State: What State do you claim for residence purposes?:
Zip: How long have you resided in that State?: Years: Months:
Ethnic Group: Black/Non-Hispanic White/Non-Hispanic Hispanic
American Indian/Alaskan American Alaskan/Pacific Islander Race Unknown
In case of emergency, notify: Relationship:
Address: Phone:
College or University Currently enrolled at
Major: Total Hours Completed:
Have you requested transcripts be sent to UHV? Yes No
Undergraduate non University of Houston-Victoria Students should have their university's registrar office send official transcripts to :
Vic Padelford, Director International Programs and Special Projects UHV, Study Abroad University West 108, 3007 N. Ben Wilson, Victoria, TX. 77901
Graduate Students applications are required to submit only the official transcript bearing proof of an undergraduate Degree.
How did you hear of UHV Study Abroad/Taiwan: -Please Select- Internet Our Catalog/Brochure Electronic Mail Mail My School A Recommendation A Representative Other
Undergraduate Graduate Expected Date of Graduation: Month Year
Course and Course # you wish to take:
Check the following categories that apply to you.
I intend to apply for Financial Aid in the fall following Taiwan Study Abroad.
If you will be taking any prescription medication during the program, or if you are under a physician's regular care check this box and notify Program Director of the circumstances in writing.
If possible I wish to room near the following program participant
Name:
Please return the completed application form with $250 deposit payable to:
UHV, Study Abroad University West 108, 3007 N. Ben Wilson, Victoria, TX. 77901
v Note: Deposits are not refundable unless you are refused acceptance in the Program or your course is cancelled.
v Qualified Applicants are accepted on a first come, first serve basis.
I hereby affirm that to the best of my knowledge all information furnished on this form is complete and accurate. I understand that withholding information requested and/or giving false information may make me ineligible for admission and enrollment. I agree that a record of my academic performance may be furnished by all institutions of higher learning that I have attended. I am eligible to return to the last college that I attended.
v I also give permission for The University of Houston-Victoria to release an official copy of my UHV Study Abroad /Taiwan
Credit to my host institution ___________________________________________ Applicant's Signature
v The Director of Study Abroad/Taiwan has the right to terminate any student’s participation should the student be deemed a danger or a threat to the integrity of the program. I understand the director may refer my application to the UHV Counseling Center or university officials in Student Affairs before I am accepted to this program.
Date:___________________ Applicant's Signature_____________________________________
Checks should be made out to UHV Study Abroad, and For Deposit only written on the back. Applications may be FAXED to (361)570- 4184 if accompanied by VISA or MASTERCARD information.
Method of Payment: Check Money Order VISA MASTERCARD
If paying by VISA or MASTERCARD Acct. #_______________________ Exp. Date__________
Card Holder's Name as written on card
Card Holder's Signature__________________________________________________