Last name (family name) First name (given name) Mailing address Home country address U.S. phone number (if applicable) Home country phone number Email address Agency name If you are working with an agency, please list the agency name. Agency email address Date of birth Year Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Gender - None -FemaleMaleOtherPrefer not to answer Country of birth - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle Of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People'S Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People'S Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSerbia And MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province Of ChinaTajikistanTanzania, United Republic OfThailandTimor-LesteTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SaharaYemenZambiaZimbabwe Country of citizenship - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle Of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People'S Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People'S Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSerbia And MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province Of ChinaTajikistanTanzania, United Republic OfThailandTimor-LesteTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SaharaYemenZambiaZimbabwe Education - None -High schoolSome collegeCollege (bachelor's degree)Graduate school (master's degree) Secondary school Please list the name and location of secondary school attended. Colleges/universities Please list name and location of any colleges/universities attended. Major (area of study) Semester applying for Fall (August) Spring (January) Year long (Fall & Spring) Year long (Spring & Fall) Certification to be read and digitally signed by all applicants to certify the accuracy of the information provided: I certify under penalty of perjury under the laws of the State of California that I have provided complete and accurate responses to all the items on this application. I further certify all unofficial documents submitted in support of this application are unaltered records that pertain to me. My signature certifies the accuracy and completeness of the information provided. I understand that any misrepresentation or omission may be cause for denial or cancellation of admission, transfer credit, or enrollment. Applicant signature (electronic) Registration certification * By checking this box, I understand that I will not be allowed to register for courses until all Cal Poly Humboldt degree seeking students have secured their class space. I understand that my registration is dependent upon the extra, available seats only. I understand that specific classes I desire or “need” cannot be guaranteed. I understand Make sure to submit: Official English Proficiency Score report Official transcripts Completed Certification of Financial Support Health insurance: You are required to have health insurance for the time you are enrolled at Cal Poly Humboldt. All international students are automatically enrolled in the CSU Healthlink program and must pay the fees each semester. You will be insured from August 10 for the fall semester and from January 10 for the spring semester. You will need to bring with you: Your latest transcript (to show completion of classes needed as prerequisites for classes you want to take at Cal Poly Humboldt). Proof of measles immunization: You are required to have been immunized (vaccinated) against measles to study at Cal Poly Humboldt. You must show proof of two doses of vaccine after age one. If you have been immunized against measles in your home country (or elsewhere), please bring proof of immunization to Cal Poly Humboldt International Programs on the first day of orientation. If your immunization record is in a language other than English, it must be translated into English. You will be blocked from registering for classes until you have been cleared by the Cal Poly Humboldt Student Health Center. Though the Student Health Center can provide these vaccines, they must do so at cost (approximately US $45). As the Student Health Center does not bill insurance companies, it is best if you receive immunizations from your own doctor, where the insurance company can be billed and the fee may be lower. Official English Proficiency Score Report Files must be less than 50 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Completed Certification of Financial Support Files must be less than 50 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Passport Files must be less than 50 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Student Consent for Release of Information Submit this form if you are working with an agency, or an agency submitting this application on a behalf of a student.Files must be less than 50 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Emergency contact Emergency contact name: Emergency contact email: Emergency contact phone number (with country code): Emergency contact address: Please make sure your emergency contact is aware that they are your emergency contact. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
