University of Denver Study Abroad Programs
Application for Non-Degree Exchange Programs 2012-13 Academic Year
2200 South Josephine Street · Denver · Colorado · 80208 · U.S.A.
I. PERSONAL INFORMATION
Name as appears in passport: ______
Last name (Family Name) First name (Given name)
______
middle Name
Date of birth: ____/____/____ Gender: ð Male ð Female
mo day year
Country of citizenship: ______Birthplace:______
CITY COUNTRY
Country of permanent residence (if different from country of citizenship): ______
Current address: ______Telephone: (____) ____ - ______
street apt/box no
______
city state Postal code country
Valid from ___/___/___ to ___/___/___
E-mail: ______@ ______
Permanent address: ______Telephone: (____) ____ - ______
street apt/box no
city state Country postal code
Emergency contact: ______Relationship: ______
Address, if different from above: ______
Telephone: (____) ____ - ______Email: ______
Are you planning to bring dependents with you to the United States? ______
II. ACADEMIC INFORMATION
Home University: ______
First Term of Study at the University of Denver:
ð Fall Quarter 20__ ð Winter Quarter 20__ ð Spring Quarter 20__
Length of Study:
ð One quarter ð Two quarters ð Academic Year (3 quarters)
Major field(s) of study at home university: ____________
Class Level at home university: ð 1st Year ð 2nd Year ð 3rd Year ð 4th Year ð Graduate
III. POLICIES FOR EXCHANGE STUDENTS
Admission as an exchange student does not admit a student to any regular University degree or certificate program. Exchange students are recorded as in “special status.” If you would like to receive a degree from the University of Denver, you must apply through the International Admissions Office. If a student applies and is admitted into a degree program, credit earned from your exchange will be re-evaluated by the appropriate department to determine applicability towards that degree. Students are limited to one academic year under the exchange program. The summer term is not available for exchange. Courses at University College, the Women’s College, and the College of Law are not available as part of this exchange program. Courses must be taken for a grade; pass/fail and auditing are not options. Students categorized as undergraduate students at DU must enroll in at least 12 credit hours per quarter, while students categorized as graduate students must enroll in at least 8 graduate-level credit hours per quarter.
I certify that I am in good standing academically and financially in all colleges and universities attended, and that all information provided above is true and complete.
Signature: ______Date: ______
NOTE: You must supply a record of your vaccinations upon arrival to the University of Denver and carry a health insurance policy to participate in any University of Denver Exchange Program.
VI. AUTHORIZATION TO RELEASE INFORMATION
I authorize the appropriate official(s) of the University of Denver to forward an official transcript or grade report of work completed to my home institution.
Signature: ______Date: ______
V. APPROVAL OF HOME INSTITUTION
I approve the applicant’s participation in this exchange program.
Signature of Exchange Coordinator: ______
Title: ______
Date: ______Email Address: ______
A COMPLETE APPLICATION INCLUDES THE FOLLOWING
Non-Degree Exchange Program Application form
Insurance Requirement Attestation form
Undergraduate students: TOEFL score of at least 570 (230 computer based test, 88 internet based test)
Graduate students: TOEFL score of at least 550 (213 computer based test, 80 internet based test. Many departments, including Business, International Studies, and Communications, have higher TOEFL requirements. For a full list of departmental TOEFL requirements, see https://admission.du.edu/admissions/grad.asp
Students must provide proof of financial support, which must be an official bank letter or bank statement verifying sufficient funds. If the student has a sponsor, please also submit a letter from the sponsor certifying willingness to support the student’s studies, relationship to the student, and complete contact information. Exchange students must provide proof of financial support in the amount of $4,800 per quarter of study at DU.
Photocopy of passport information/photo page(s)
Transcript, translated into English, that shows the current level of education
Proof of MMR vaccinations (bring to the University of Denver and give to the Health Center): form on-line at http://www.du.edu/duhealth/pdfs/immunizationForm.pdf, or bring vaccination record.
APPLICATION DEADLINES
Fall quarter: April 15
Winter quarter: September 15
Spring quarter: January 15
INSURANCE REQUIREMENT ATTESTATION FORM
THIS FORM MUST BE COMPLETED, SIGNED AND RETURNED TO INTERNATIONAL STUDENT & SCHOLAR SERVICES. THIS FORM MUST BE COMPLETED AGAIN BEFORE A NEW DS-2019 CAN BE ISSUED FOR EXTENSION OF STAY OR A DEPENDENT.
Mandatory Insurance Requirement Information
The following information regarding insurance must be read, signed, and returned to this office to process a request for issuance of Form DS-2019.
Insurance Requirement: Under the regulations of the United States Department of State effective September 1, 1994 all individuals who receive a Form DS-2019 (J-1 visa document) and enter the U.S. in J-1 exchange visitor status will be required to have medical insurance to cover themselves and any accompanying J-2 dependents for the duration of their programs. The insurance coverage must provide the following minimum coverage:
· Medical benefits of at least $ 50,000 per accident or illness;
· Repatriation of remains: $ 7,500;
· Medical Evacuation: $10,000;
· Deductible of $500 or less per accident or illness;
· Co-insurance paid by J-1 not to exceed 25% of covered benefits per accident or illness.
The company providing the insurance must have:
· an A.M. Best rating of “A-“ or above;
· an Insurance Solvency International, Ltd. (ISI) rating of “A-1” or above;
· a Standard & Poor’s Claims-paying Ability rating of “A-“ or above;
· a Weiss Research, Inc., rating of B+ or above; or
· be backed by the full faith and credit of the exchange visitor’s home country.
Failure to comply with this requirement will result in the termination of the exchange visitor's program!
I understand that as a J-1/J-2 visa holder, I am required to maintain health insurance with the minimum coverage as specified above for myself and any accompanying dependents. I hereby affirm that I have, or will have by the time I begin my visit at the University of Denver, the stated insurance for the effective period of all valid forms DS-2019 issued to me.
(Exchange Visitor Signature) (Date)
(Exchange Visitor Name) (Date of Birth)
(Address ) (E-mail Address)
Please note that in addition to the mandatory insurance requirement necessary to process the Form DS 2019, all students at the University of Denver are required to have health insurance. You may either purchase a policy at the University of Denver (see http://www.du.edu/duhealth/general/insurance/index.html) or use your own policy. To waive the DU Student Health Insurance Policy after your arrival, you will be asked if your policy meets the following standards:
Does your current health insurance plan have a maximum coverage limit of at least $500,000 per illness or injury?
Does your current health insurance plan have a deductible amount or co-payment that you can afford to pay?
Does your current health insurance plan have adequate mental health coverage?
Will your current health insurance plan cover all the services you may need while you are in Denver, Colorado, anywhere in the US or abroad?
Will your current health insurance plan be effective from the time you arrive until you depart the U.S.?