The second deposit ($3575) due on March 28 needs to be accompanied by the T-Pay form as well. Ensure that your banner account has posted that fee before paying.
Office of the University Bursar
150 Student Services Building,
Blacksburg, VA, 24061
Phone: 540-231-6277
Email: bursar@vt.edu
Fax: 540-231-3238
Student Number:____________________________
Date of Birth:____________________________
Passport Number: ____________________________
Citizenship: ____________________________
Gender (check one): ______ female _______ male
E-mail Address: ____________________________
Projected year of graduation:____________________________
Major(s): ____________________________Minor(s): ____________________________
College: ____________________________ (e.g., CLAHS, Pamplin, etc.)
Grade Point Average: ____________________________
Local Mailing Address and phone:
_______________________________________________________________
_______________________________________________________________
(City)____________________________(State)__________(Zip)_______
Phone: ____________________________
Name, address, and phone of parent(s) or legal guardian(s):
parent/guardian 1:
_______________________________________________________________
_______________________________________________________________
(City)____________________________(State)__________(Zip)_______
Home Phone: ____________________________
Work Phone: ____________________________
parent/guardian 2 (if applicable):
_______________________________________________________________
_______________________________________________________________
(City)____________________________(State)__________(Zip)_______
Home Phone: ____________________________
Work Phone: ____________________________
Person to contact in case of an emergency (put same if parents or legal guardians above):
(Name)______________________________
(Address)_____________________________________________
______________________________________________________
______________________________________________________
(City)____________________________(State)_________(zip)_________
Home Phone:____________________________
Work Phone: ____________________________
Will you be applying for financial aid? _____ yes _____ no
(Note: Those interested in applying for financial aid MUST complete additional paperwork, and should do so as early as possible. Please contact the Office of International Research, Education & Development for information.)
Are you currently enrolled as a student at Virginia Tech? _____ yes _____ no
(Note for non-VPI&SU students: If you are not already a student at VT, you must also apply for admission to the university for special student status. There is a simple online form especially for visiting summer students, available through university admissions.
Indicate your involvement/participation in extracurricular French activities (e.g., Le Cercle Francophone, Frenchship).
For which courses would you like to receive credit in France? (Choose from the list of courses on the announcement).
Do your have any knowledge of French not acquired in the classroom? If so, please explain.
Have you had any previous significant (longer than just a few days) travel outside the USA? When, where, and for how long?
Is there any other special information (smoker/non-smoker, medication, etc.) which you would like us to take into consideration?
Will you be flying TO Paris with the group, or will you arrive separately?
If you are flying to Paris with the group, would you like to take advantage of the independent travel time (at possible additional expense) before or after the Program?
If you do plan to stay in France for independent travel, how long do you intend to stay and on what date would you like to leave/return?
If you are flying to Paris with the group, how do you plan to get to Washington, DC from your home and back again?
Additional special requests and arrangements, including dietary restrictions. If you are vegetarian, indicate what you do not eat. How strict are you?
Please sign and return this form contingent upon the following statement:
I have no communicable disease, physical condition, mental condition, or recurring ailment which is likely to require medical, surgical, or psychiatric attention during the time of the Virginia Polytechnic Institute & State University Summer Study Program in France or prevent or limit my efficiency in matters of studies and normal recreation, be detrimental to the welfare of the group of other students in the Program, or require unreasonable attention of the group's directors, teachers, or of the host family or residence where I will be lodged.
Date: ____________________________Signed: ____________________________
Mail or bring completed form to: