NAME:__________________________________

Social Security Number:_____________________

Date of Birth:______________________________

Country of citizenship:_______________________

Program:__________________________________

(examples: International Student Teaching, Graduate Research, etc.)

Departure date:________________________________

Return date:___________________________________

Credit card number:_____________________________

Visa ___ Master Card______ American Express____

Expiration date:_____________________________

Amount of Charge:___________________________

($21.00 per week x number of weeks abroad. NOTE:

Minimum enrollment period is 2 weeks)

Please list the address where your insurance card should be sent:

Street address:_______________________________

City:_______________________________________

State and zip code:____________________________

Phone:______________________________________

Email:_______________________________________

Return this form to the Office of International Programs, CBC B 325.

Please call 895-3896 if you have any questions.

APPLICATIONS MUST BE SUBMITTED NO LESS THAN 30 DAYS PRIOR TO DEPARTURE.