University Of California Intercampus Visitor Program Application Form

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University of California
Intercampus Visitor Program
AppLICAtIon Form
$70 Nonrefundable Fee Required. Payment made by check or money order should be made payable to
The Regents of the University of California.
Before filling out this application, carefully read the instructions on pages 3– 4.
SECTION A
PlEAsE tYPE OR PRint in inK
1. Name (Use full name exactly as it appears on your current University records.)
lAst nAME
fiRst nAME
MiddlE nAME
2. Student I.D. number
3. U.S. Social Security Number*
4. Birthdate
___________________________
_____________________________
_______________________
MM/dd/YYYY
5. This is an application for the
campus for the
term, 20
fAll/wintER/sPRing
nd stREEt
hOst
CAMPusnd stREEt
YEAR
nd
6. Currently enrolled at the
campus for the
term, 20
hOME
CAMPusnd stREEt
fAll/wintER/sPRing
nd stREEt
YEAR
nd
7. Major (or proposed major) at home campus
8. Total units completed
nuMBER And stREEt
nuMBER And
9. Current level
Freshman
Sophomore
Junior
Senior
10. Mailing address
11. Telephone
nuMBER And stREEt
nuMBER And stREEt
CitY
stAtE
ziP
12. Permanent address
13. Telephone
nuMBER And stREEt
nuMBER And stREEt
14. E-mail
CitY
stAtE
ziP
PlEAsE usE YOuR uC CAMPus E-MAil AddREss
15. Are you a California resident?
Yes
No
16. What is your country of citizenship?
nuMBER And stREEt
17. If not a U.S. citizen, what type of visa do you hold?
nuMBER And stREEt
18. Do you want to be considered for financial aid while you are a visitor?
Yes
No
If yes, you must apply for financial aid at the host campus (see instructions on page 3).
If you currently receive financial aid, have a campus Financial Aid Officer sign here.
finAnCiAl Aid OffiCER
19. Have you ever been a registered student at the host campus?
Yes
No
If yes, indicate all dates of attendance. ________________________________________________________________________
20. Are you applying to a special program at the host campus?
Yes
No
If yes, indicate name of program. (Subject to approval of host campus.) ___________________________________________
* The Social Security Number you provide on this form will be used by the University to verify your identity and will be reported to the Internal Revenue Service pursuant to the Taxpayer’s Relief
Act of 1997. Disclosure is mandatory. This notification is provided to you as required by the Federal Privacy Act of 1974. The University’s record-keeping systems related to this application
were established prior to January 1, 1975, pursuant to the authority granted to The Regents of the University of California under Article IX, Section 9, of the California Constitution. If you
are a United States citizen and do not have a Social Security Number, apply for one through the nearest district Social Security Administration office and notify the Admissions Offices when
you receive it. If you are not a United States citizen and live in another country, it is not necessary for you to secure a Social Security Number.

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