Lincoln Memorial University – Student Exchange Application
Please check:
One academic semester: Sept. 2017 to Dec. 2017 ______
One academic year: Sept. 2017 – May 2018 ______
PART I: To be Completed by the Applicant (Please type or print clearly.)
1. Name: (as it appears on your passport or birth certificate)
Last (family or surname)
Middle or maiden
First (given)
2. Home institution:
3. Nationality: 4. Sex: □male □female
5. Date of birth 6. Place of birth:
month / day / year
/ /
7. Write your address as it would appear on an envelope, using one line for each line of your address.
a. Address: (valid until month day year )
Telephone (with country and area code):
E-mail:
(E-mail will be sent to this e-mail address)
b. Permanent address: (mail will be sent to this address after the date given above)
Telephone (with country and area code):
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8. a.) Specify the country or countries in which you have citizenship:
b.) Specify the country or countries of which you are a legal permanent resident:
9. Person(s) to contact in case of emergency:
Name(s):
Address:
Telephone (with country and area code):
Relationship to you:
10. Highest degree completed or in progress:
Major field:
Completion date: month / year /
Minor field:
Completion date: month / year /
11. Principal field(s) of intended study at Lincoln Memorial University (LMU)
Specific interest, if any, within this field:
12. Academic level at (at the time of application)
□Undergraduate (BA or equivalent)
□1st □2nd □3rd □4th
□Graduate
□1st □2nd
13. Please describe any special needs or services you will require while at LMU (e.g., dietary considerations, learning aids, or facilities with handicapped access).
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14. List any subjects, including research topics, that you wish to study during the period of study at LMU.
15. Indicate academic work in progress. List specific courses if applicable.
16. I authorize the coordinator at my University to send my official academic records / transcripts to LMU.
□yes □no
I authorize the official academic records / transcripts of work I undertake at LMU to be sent to my University.
□yes □no
Should I be accepted as an exchange student at LMU, I agree that:
□ I will take part in all aspects of the program, including orientation and evaluation.
□ My exchange placement may be terminated at any time by LMU or by my home institution if I fail to remain enrolled as a full time student at the exchange University, fail to maintain minimum academic standards defined by the exchange University, or am found by exchange University to be in violation of laws or regulations of my host country or the exchange University.
17. I acknowledge that all my statements on this form are complete and accurate to the best of my ability and knowledge.
Applicant's signature:
Date:
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PART II: To be Completed by the applicant’s international studies coordinator
18. Does the applicant above have any special conditions that LMU should be aware of during the program period?
19. Indicate further details on the applicant that LMU should consider in placing the student, if any (e.g., special interests pertaining to the academic program).
20. I have reviewed Part I of this Participant Profile form and discussed it with the applicant. I support this nomination. I confirmed that the applicant has received approval for participating in this exchange program from all required faculty members and administrative officials, and that the required information for LMU’s placement has been fully provided.
Signature of University’s Coordinator
Name (type or print):
Date:
*Please attach the latest transcript from the Home Institution.
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