Supplement for International Law/Graduate Student Applicants

In order for the International Student and Scholars office to issue the documents necessary for you to obtain a US student visa, you are asked to complete the following information. Please type or print clearly. Complete every question.

1. Student's name as in passport: (Family name first) _________________________________________

2. Date of birth (Month/Day/Year)__________________________ 3. Gender _____________________

4. Citizenship_________________________ 5. Country of residence ___________________________

6. City and province of birth___________________________ 7. Country of birth__________________

8. Degree being sought (JD, LLM, MAT, MEd, etc.)_____________ 9. Beginning semester ______________

10. Amount and source of funding (Attach proof)____________________________________________

11. Has Lewis & Clark offered you a scholarship/fellowship?____________ 12. Amount____________

13. Career position in your home country__________________________________________________

14. Are you currently in the US?_________________ 15. If so, on what type of visa?_______________

16. US Social Security number (if you have one)_____________________________________________

17. Marital status __________18. If married, will your spouse and children accompany you?_________ (Note: For information on the costs of accompanying dependents, refer to the "Dependent Expenses" website at http://www.lclark. edu/dept/iso/ugdependents. html

19. List the names, relationship, birthdates, and places of birth of dependents who will accompany you.

20. Amount and source of funding for your dependents (attach proof)____________________________

21. Are you aware that Lewis & Clark requires health insurance for all international students and their dependents? __________ 22. What arrangements will you make for insurance coverage? ____________ _____________________________________________________________________________________ (Note: For information on insurance, refer to the "Health Insurance Options" website at: http://www.lclark. edu/dept/iso/insurance. html)

23. List your overseas home address (not an address in the US). Print carefully.

24. List the address where you want to receive the US INS documents (if different from above). Print carefully.

25. Your e-mail address_________________________________________________________________

26. Your telephone number (with country & city code) _______________________________________

27. Your fax number (with country & city code) ____________________________________________

Return this form with your application OR mail or fax it to:

International Students and Scholars
MSC 192 - Lewis & Clark College
0615 SW Palatine Hill Road
Portland, Oregon 97219-7799
TEL: 503-768-7305
Email: iso@lclark.edu
FAX: 503-768-7301