MARYLAND INSTITUTE COLLEGE OF ART

Registration Form

International Student Bridging Program

Must be received with enrollment fee by or May 20, 2016 (graduate students)

q Yes, I would like to register for the International Student Bridging Program on August 1, 2016- August 26, 2016.

PERSONAL INFORMATION

Name: ______

Last (family) name First (given) name Middle name

Date of Birth: ______Sex: Male ___ Female ___

Example: July 28, 1990

Phone Number (with country code): ______E-mail Address: ______

HOUSING INFORMATION

All students are required to live on campus during the International Student Bridging Program from August 1, 2016- August 26, 2016.

.

I will be a/an: ___ graduate student

___ other (please specify ______)

During the ISBP, I would like a ___ single bedroom.

___ double bedroom. With ………… (no price difference for a single or double room)

Please complete and return this document by mail or fax to:

Office of Graduate Admission

Graduate Studio Center

Maryland Institute College of Art

131 W. North Avenue

Baltimore, MD 21201 USA

Email: ; Fax (410) 225.5275

Fall 2016 ISBP- GRD

PAYMENT INFORMATION

The enrollment fee of $2850 covers the total cost of the program, including housing and all meals. Payment is non-refundable and must be received by May 20, 2016 for graduate students.

Please check the appropriate box below:

Payment Method: / qCheck enclosed / q Credit Card
(Please call MICA's Student Accounts office at +1 410-225-2356 Monday- Friday between 9:00 am-5:00 pm Eastern Standard Time.) / q Wire Transfer*
Sent on (date) ______

*Wire Transfer Instructions (Payment from Foreign Banks only)

The following information is needed to complete a wire transfer. Please include student’s name so that the payment will be credited to your account. If you have any questions about wire transfer, please call MICA's Business office at +1 410-225-2209.

Bank Name: M & T Bank

Address: 1 M&T Plaza

Buffalo New York, 14203 USA

ABA Number: 022 0000 46

Account Number: 070-8413-4

Swift Number: MANT US 33 INT

Account Name: Maryland Institute College of Art

Comment: Student’s name and MICA ID# (may be found on MICA mailing label above student’s name)

HEALTH AND EMERGENCY INFORMATION

Do you have any medical conditions that might affect your stay at MICA? (Circle one) Yes No

If yes, please explain: ______

______

EMERGENCY CONTACT PERSON:

Name: ______Relationship: ______

Telephone Number (with country code): ______

Mailing Address: ______

E-mail address: ______

Fall 2016 ISBP-GRD