Peralta Community College District Berkeley City College | College of Alameda | Laney College | Merritt College

Office Of International Education 333 East 8th Street, Oakland, CA 94606 USA

Website: web.peralta.edu/international Email : globaled@peralta.edu | Phone: (510) 466-7380 | Fax: (510) 465-3257

International Student Application Form

Admissions Process

STEP 1: Submit a completed application, $50 (US) non-refundable application fee payable to PCCD (Visa or MasterCard credit card, check or money order - no cash accepted) andother required documents (See Application Checklist* for complete list) to the Office ofInternational Education (333 East 8th Street, Oakland, CA 94606 USA).

STEP 2: Student will be contacted within approximately 2 weeks confirming receipt of the application. If the application is incomplete, you will be requested to submit the missing/incomplete documents.

STEP 3: Complete the CCCApply online application to create a student account

STEP 4: After you have completed the CCCApply online application, you will receive an automated email with your Student ID number. You must submit your Student ID number to the Office of International Education in order for your application to be officially accepted.

STEP 5: Upon submitting your Student ID number to the Office of International Education, we will provide you with an official letter of acceptance and your Form I-20. For transfer students: A Form I-20 will be issued to you after your previous schoolreleases your records in SEVIS and you have enrolled in the minimum number of units required for your starting semester (12 units for Spring and Fall).

Summer review period begins no later than March | Fall review period begins no later than April |

Spring review period begins no later than October

Late applications may be accepted on a case-by-case basis.

All tuition and enrollment fees will be due when you register for classes.

Applicants Applying from Overseas: Students applying outside of the U.S. who will apply for an F-1 visa

Summer Semester (June – July)..…………...APRIL 1

Fall Semester (Aug – Dec)………………………..JUNE 1

Spring Semester (Jan – May)……………………NOV 1

Applicants Applying from within U.S.: Students already in U.S. with an I-20/F-1 visa orStudents on a different visa (J-1, B-2, etc)

Summer Semester (June – July)…………….MAY 15

Fall Semester (Aug – Dec)………………………JULY 15

Spring Semester (Jan – May)………………….DEC 15

Admissions Deadlines:All application items must submitted by the deadline below

International Student Application Checklist

Complete and submit this form along with the items below to the Office of International Education:

Check: make payable to PCCD

International Student Application & Checklist:

International Student Application Checklist (this page)

Page 1: A. Student Information & B. Visa Information

Page 2: C. Sponsor/Local Contact/Agent Info. & D. Parent/Legal Guardian & Emergency Contact

Page 3: E Educational Background & F. English Proficiency & Academic Goals

Page 4: G. Financial Information & H. Health Statement

Page 5: I. International Student Agreement Form

Page 6: Personal Essay

Transcripts & Diploma (Translated into English). All transfer students are required to submit unofficial transcripts from previous institutions.

High School Transcripts and High School Diploma or

University Transcripts and High School Diploma or

University Transcripts and University Diploma

Medical Examination/Immunization (Translated into English). Select which you submitted:

Please submit proof of immunization (See Section I: Health Statement for details) or

*Supplemental Page B: Medical Examination Form

Credit Card Payment Form, Supplemental Page A, Page B and Pathways Release Form can be found online at: http://web.peralta.edu/international/how-to-apply/documents-and-forms/

Bank Statement:

Must be within 6 months of the incoming term and contain name, portion of account

number, date of statement and total funds available

Copy of your Passport Biography page

Change of Status:

Copy of current visa and related documents (for example: DS2019)

Transfer Students:

Submit by Mail to:Office of International Education ATTN: International Admissions 333 East 8th StreetOakland, CA 94606 USA

Submit by Email as an attachment:To: globaled@peralta.edu Subject: Application: Student NameSave file as a PDF with student name, college and term Example: Jon Doe - BCC Spring 2018

$50 Application Fee

*Credit Card: Visa, Discover or MasterCard (link to the form is below) or

OPTIONAL: UC Berkeley Pathways: Fall Overseas Applicants; Submit Pathways Release Form by Jan 15

Copy of All I-20's Copy of Visa & I-94 Printout Certification of F-1 Student Status (Transfer-In Form)

Passport & Visa Pages:

International Student Application

A. STUDENT INFORMATION

P e r a l t a C o m m u n i t y C o l l e g e D i s t r i c tBerkeley City College | College of Alameda | Laney College | Merritt College

Office of International Education • 333 East 8th Street, Oakland, CA 94606 Tel. (510) 466-7380 • Fax (510) 465-3257 • Email globaled@peralta.edu www.peralta.edu • http://web.peralta.edu/international

I am applying for admission to (location):

Berkeley City College (Berkeley)

College of Alameda (Alameda)

Laney College (Oakland)

Merritt College (Oakland)

My first semester will be the:

Spring Summer Fall

20_________ Semester

I plan to enroll in (select all that apply):

English as a Second Language (ESL) Program

Academic Program – Associate/Certificate/Transfer Courses

Last Name:

First Name:

Middle Name:

Date of Birth:

Gender: Male Female

Country (Birth):

Citizenship:

Peralta ID: (If Known)

Student Phone: Student’s Personal Email:

Permanent Address in Home Country (not in the U.S.) REQUIRED:

Street Name, Number, District:

City, Province, Country:

MONTH, DAY, YEAR

Check if the address above is the same as your mailing address

Check if the address above is the same as your mailing address

U.S. Address (if known): REQUIRED for Transfer/Change of Status Students:

Street Number, Name: City, State, Zip:

This is my current address I will be moving and will provide a new address (provide new address as soon as you move)

U.S. Address (if known): REQUIRED for Transfer/Change of Status Students:

Street Number, Name: City, State, Zip:

This is my current address I will be moving and will provide a new address (provide new address as soon as you move)

Please select the box below relating to your Visa information: application deadlines on cover page

Transfer Student: I am currently in the U.S. as an F-1 student and will transfer my I-20

SEVIS (I-20 ) Number: N

Current School Attending: City:

Change of Status: Currently in the U.S. on a different visa and want to change to F-1 without leaving U.S.

Other: What Visa do you have: B-1 B-2 J-1 J-2

Departure Date: (Date stamped in Passport)

Overseas Applicant: I need an I-20 as I am applying for an F-1 visa

___________________________

B. VISA INFORMATION

Page 1 - TTG - 9-14

Page 1 - TTG - 3-17

STUDENT NAME: Date of Birth: MONTH, DAY, YEAR

D. PARENT/LEGAL GUARDIAN INFORMATION & EMERGENCY CONTACT INFORMATION

C. SPONSOR/LOCAL CONTACT/AGENT INFORMATION

Father’s Name: Job: Address:

Job:

If the student will be under 18 years of age and not married when attending school, the Parent or Legal Guardian must sign below.

Signature: Name: Date:

Emergency Contact Information:

Name: Phone: Email:

This application is being submitted by (include name):

Family/Friend:

Sponsor:

AgentΥ

MONTH, DAY, YEAR

Family/Friend, Sponsor or Agent Representative please complete the section below:

Contact Name:

Address:

City, Country:

Email:

Phone:

Additional Contact:

Additional 9ƳŀƛƭΥ

Additional tƘƻƴŜΥ

Once a student arrives, no information regarding the student, their application or status will be communicated to local contact unless the student has completed an Authorization of Release of Records Form and indicates that you may receive this communication.

I am representing the student in their application and will submit to the Office of International Education application materials and other items. I will truly and fairly represent the student and will relay information regarding admissions, procedures and requirements to maintaint their F-1 status in good faith. I understand that once a student arrives, an Authorization of Release of Records must be submitted by the student to receive further communication regarding their application, status, enrollment and/or academics.

Signature: Date:

Family/Friend, Sponsor or Agent Representative please read this statement and sign below:

Mother’s Name:

Legal Guardian: Job:

/ƛǘȅΣ 5ƛǎǘNJƛŎǘ:

CountryΥ

Student

Family/Friend, Sponsor or Agent:

Complete the next two sections

Student: Go to Section D Parent/Legal Guardian Information & Emergency Contact

Please complete the section below with the student's Parent/Legal Guardian information. A Legal Guardian is a person who has legal authority to care for the student in place of their parents.

Name: Phone: Email:

Page 2 - TTG - 3-17

STUDENT NAME: Date of Birth: MONTH, DAY, YEAR

E. EDUCATIONAL BACKGROUND

F. ENGLISH PROFICIENCY & ACADEMIC GOALS

Please list all schools that you have attended. In addition, please submit one of the following in English:

1) University transcripts and diploma 2) High School transcripts and diploma 3) University transcripts & High School diploma

High School College/University Other

Name

Country

Dates Attended

Major

Have you graduated from high school (secondary)?

YES, I have graduated from high school on this date (Month/Year): ,

NO, I am still attending high school and will graduate on this date: ,

NO, I have not graduated from high school and will not graduate before attending the Peralta Colleges

Have you graduated from a University (Bachelor/Masters)?

YES, I have graduated from University: Bachelors Masters/PhD

NO, I have not graduated from University

English Proficiency:

What is your Native Language?

If No, how long have you studied English after high school?

0-1 year 2-3 years more than 3 years

Are you planning ǘo takŜ ESL Classes? YES NO

Have you taken TOEFL/IELTS/other? YES NO

Test:

Score:

Date:

If attended a ¦Φ{Φ Language School, please list

Completed/Current Level:

Dates Attended:

Improve English

Complete an Associate 5ŜƎNJŜŜ or Certificate Program

Meet Transfer Requirements for Bachelor’s Degree

-List two universities you are interested in:

Universities:

Universities:

Prepare for Graduate School όaŀǎǘŜNJǎκtƘ5ύ

-List two graduate schools you are interested in:

Universities:

Universities:

MONTH, DAY, YEAR

Submit Score

Report

Page 3 - TTG - 3-17

Academic and Career Plans: (Available majors on last page)

What is your intended major?

How many years do you plan to study at PCCD?

What is your academic goal? (select all that apply)

All students must take an ESL placement exam to determine specific ESL or English level. Students may submit transcripts from U.S. university for English placement.

STUDENT NAME: Date of Birth: MONTH, DAY, YEAR

G. FINANCIAL INFORMATION

H. HEALTH STATEMENT

All international students must demonstrate that they are able to pay tuition and all associated costs. The Peralta Colleges does not offer scholarships for prospective students. Students on a scholarship from their home country or agency must submit proof of financial support. U.S. Sponsors may be required to submit an I-134 Affidavit of Support with an accompanying bank statement.

Please select who will pay for the student’s education and amount per year.

Student: Family: Sponsor: Scholarship: AMOUNT AMOUNT AMOUNT

Total Funding (USD): $

Total Required (USD): $ 20,722 - Total Funding above must be at least this amount.

Do you have any dependents? If yes, please complete Dependent Form and add costs to Total Required and put new total here: $

Are there any currency restrictions in your home country? YES NO

If yes, please explain:

Breakdown of Costs - Tuition costs are determined by actual class enrollment. Room & Board and Health Insurance costs may vary.

NO

Peralta Community College District requires all F-1 International Students to have Health Insurance. By applying, you understand that you will also have to enroll in the plan selected by Peralta.

More information about the current plan can be found at:http://web.peralta.edu/international/849-2/student-health-insurance

Students must also submit a recent immunization record (translated) or Medical Exam Form that shows they are in good health.

Tuberculosis (PPD and X-rays if necessary) Measles Tetanus-Diphtheria Mumps Polio Rubella

More information about the current plan can be found at:http://web.peralta.edu/international/how-to-apply/documents-and-forms/

Have you ever had any of the following conditions?

Frequent headaches, hearing difficulty, rheumatism/rheumatic fever, heart disease, lung disease, digestive/stomach pain, operation/severe injuries, hernia, arthritis, frequent dizziness/fainting, epilepsy/seizures, high blood pressure, kidney disease, nervousness or other condition

YES NO

If yes, please submit a separate page detailing each condition

Are you in good physical and mental health?

YES NO

I understand that I need to provide proof of health insurance and that it needs to cover my entire duration of program at PCCD. I also certify that the information in the Health Statement section are true and correct and that I may be denied admissions or be dismissed by providing false, or misleading information

Signature:

Name:

All international students are required to enroll in the Peralta Health Insurance Program (PHIP). Upon enrollment, students will be automatically registered to receive health insurance and charged a health insurance fee for the entire semester. We suggest that students cancel any preexisting insurance coverage before attending the Peralta Colleges or that they understand that they are paying this in addition to PHIP.

$

46/unit $ 230/unit

$ 15/unit

$ 4/campus

$ 56/Semseter

Tuition Fees Enrollment Fee Non-Resident Tuition Capital Outlay Fee Total Per Unit: $ 291/unit*

Per Year (estimated costs)

$ 8,730 $ 10,000

$ 1,874 $ 118

30 units Tuition Room & Board (Living) Books, Insurance AC Transit/Health Fee Total : $20,722 USD

Page 4 - TTG - 3-17

AMOUNT

Family/Sponsor Name & Relationship:

I understand that I must submit proof of vaccinations or submit Medical Examination Form (link below).

Please answer the question in bold below:

Do you understand and agree to purchase the mandatory Health Insurance? YES

Mandatory Fees :Student Rep & Campus Fee AC Transit/Health Fee Health Insurance FeeTotal (Fall Semester):

$ 114.50/month ** $ 632.50***

*Fall 17 estimated enrollment costs for 12 units at one campus: $ 4,124.50

**Health Insurance Fee: Spring term January - July; Fall term August - December; Summer term June & July

S D AM : Date of irth: M H, DA , A

. INTERNATIONAL STUDENT AGREEMENT FORM

& ACADEMIC GOALS

International Student Orientation: nderstand that am re ired to attend the International Student Orientation prior to my first semester. The orientation date is about one week prior to school.

Reduced Course Loads: nderstand that m st obtain prior permission from the ffice of nternational d cation to enroll in less than full-time. The reasons are listed in the handbook

Academic Objective: nderstand that will complete my st dy ob ective as declared on this nternational St dent Application Form and pdate the nternational ffice of any chan es to my ma or

or pro ram

5 Student Education Plan: nderstand that m st disc ss my classes with a co nselor prior to each semester and are required to complete a Student ducation lan, to determine co rses re ired to complete my academic objective.

Online Enrollment: I understand that only 1 course or 3 units will count towards full-time enrollment each semester. Enrollment in more online classes or units will not count towards my full-time enrollment. Hybrid courses are not considered online classes.

Financial Obligations: nderstand that in order to re ister each semester, m st pay my entire t ition before the be innin of each semester or as re ister for classes after this time Failure to pay tuition may result in Termination of my student status if it prevents me from enrolling.

Health Insurance Fee: I understand that as a Peralta International Student I will have to pay the Health Insurance Fee each semester and will follow all rules and deadlines for payment and refund.

nderstand that m st notify the ffice of nternational d cation if there are any chan es to mylocal address, email address and or phone number

0 Departure/Transfer Out: nderstand that m st notify the ffice of nternational d cation in writing for a eave of Absence, withdrawin or transferrin to a new school

nderstand that m st notify the Office of International Education of any changes in my statusincl din , b t not limited to, transferrin to another colle e, or ret rnin to my home co ntrypermanently Failure to do so may result in Termination/Completion of my student F-1 status

Please initial next to each statement and sign at the bottom hese are some of the primary r les and responsibilities that each international st dent m st follow to maintain their F-1 status. his list is only a portion of the r les Please refer to the nternational St dent Handbook or ask a Desi nated School fficial (DS ) if yo have additional estions concernin F stat s r les and re lations

have read and nderstand these statements and will follow these r les and instr ctions nderstand that fail re to do so may res lt in ermination of my F stat s also nderstand that there are other r les that m st follow and to ask a DS at the Peralta Colle es if have any estions or concerns

Student Signature: Date:

understand that must enroll full time and complete a minimum of units semester ith satisfactory grades (2.0 GPA or better) or be sub ect to dismissal.

o ou hea a out us

Family Member Friend

St dy

ecr itment A ency: an a e School: d cation Center: ther:

__________________ __________________ __________________ __________________

Pa e 5 TTG - 3-17

Colle e Fair: ebsite:

Advertisement: Ma a ine:

Prompt: Please describe your academic goals, your plans are after completing this goal and

why you have chosen to attend the Peralta Colleges. You may use additional pages if necessary or submit your Personal Essay separately from this application.

Title:

STUDENT NAME: Date of Birth: MONTH, DAY, YEAR

Page 6 - TTG - 3-17

ASSOCIATE DEGREE AND CERTIFICATE PROGRAMS BERKELEY ALAMEDA LANEY MERRITT

Administration of Justice

African American Studies

American Sign Language

Anthropology

Apparel Design & Merchandising

Architecture

Art

Asian and Asian-American Studies

Auto Body and Paint

Automotive Technology

Aviation Maintenance Technology

Biology/ Biological Sciences/Bioscience

Biomedical Engineering Technology

Biotechnology

Business

Carpentry

Child Development

Chronic Care Assistant

Communication

Community Social Services

Computer Information Systems Construction Management

Cosmetology

Culinary Arts

Dance

Dental Assisting

Diesel Mechanics

Economics

Education

Electricity/Electronics Technology

Emergency Medical Technician I

English

English as a Second Language (ESL)

Environmental Control Technology

Environmental Management and Technology

Ethnic Studies

Global Studies

DEG

REE

S A

ND

CER

TIFI

CA

TES

(20

15

-20

17

)

=Associate Degree and/or Certificate Program Available

(For most recent College Catalogs and specific Associate Degree and/or Certificates courses visit: http://web.peralta.edu/admissions

ASSOCIATE DEGREE AND CERTIFICATE PROGRAMS BERKELEY ALAMEDA LANEY MERRITT Graphic Arts

Health Sciences

History

Human Services

Humanities

Journalism

Kinesiology

Labor Studies

Landscape Horticulture

Language Arts

Liberal Arts

Machine Technology

Mathematics

Media Communication

Medical Assisting

Mexican and Latin-American Studies

Multimedia Arts

Music

Nursing

Nutrition and Dietetics

Paralegal Studies

Philosophy

Photography

Political Science

Psychology

Public and Human Services

Radiologic Science

Real Estate

Science

Social Sciences/Social & Behavioral Sciences

Sociology

Spanish

Theatre Arts

Transfer Studies (General Studies)

Welding Technology

Women’s Studies

Wood Technology

DEG

REE

S A

ND

CER

TIFI

CA

TES

(20

15

-20

17

)

=Associate Degree and/or Certificate Program Available

(For most recent College Catalogs and specific Associate Degree and/or Certificates courses visit: http://web.peralta.edu/admissions