Student Information Form

Basic Information

*First Name

*Middle Name (If no middle name, please enter “N/A”.)

*Last Name

*Date of Birth (mm/dd/yyyy)

*Gender MaleFemale

*Program Destination

*Program Name

*International Airfare

See the “Secure your international airfare” or similarly-worded step in your To-Do List. If this step is not included in your list, select N/A.

*Nationality

Contact Information

*Preferred Email Address

*Daytime Phone

Evening Phone

Passport Information

*Citizenship (Country)

*Address Street 1

Address Street 2

*City

Zip code (if USA)

State (if USA)

*Country Passport Issued By

*Passport Number

*Expiration Date (mm/dd/yyyy)

If you do not currently have a passport, enter “N/A” in the Passport Number and Expiration Date fields.

Emergency Contact

*Name

*Relationship

*Email Address

*Country of Residence

*Home Phone Number (include country code)

Cell Phone Number

Applicant SignatureI declare that:

The above information and the documents included in my application are accurate and correct to the best of my knowledge.

I agree to abide by the laws of my program’s host country and agree not to engage in any illegal activities during my academic pursuits.

I have read and I accept CLI’s Terms and Conditions. (If Program Participant is under the age of 18, this section must be completed by his/her legal parent/guardian.)

Electronic Signature of Applicant I agree with all declarations stated above.