Application for Short Term CSM Sponsored International Trips

K. Godel Gengenbach, Ph.D., Director
Office of International Programs
Stratton Hall 109 Golden, CO 80401
Tel. (303) 384-2121 Fax (303) 384-2125
http://www.mines.edu/academic/lais/oip
kgengenb@mines.edu

Permanent Contact Information:

CWID (Campus ID Number):
Last Name: First Name:
Middle Initial:
Preferred Name:
Permanent Address Line 1:
Permanent Address Line 2:
City: State:
Zip Code: Country:
Telephone Number:
CSM Email: @mines.edu
Alternate Email:

Personal Information:

Date of birth (month/day/year):
Gender: MaleFemale
Marital Status: MarriedSingle
Citizenship: US Colorado Resident
US Out of State Resident
Non-US Citizen Country:
Other fluent languages:
Passport Number:
Passport Country:
Passport Expiration Date (month/day/year):

Health Insurance Information:

Carrier:
ID Number:
Phone:

Emergency Contact Information:

Name:
Relation to You:
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Cell Phone:
Email:

Current Campus Information:

Campus Address Line 1:
Campus Address Line 2:
City: State:
Zip:
Campus Address Valid Until (month/day/year):
Major: Minor:
Current Class Standing: FR SO JR SR GR
Anticipated Graduation: Fall or Spring 20
CSM Cumulative GPA:

Program Information:

Faculty Sponser:
Course:
Destinations:
Dates:

Financial Information:

Do you recieve financial aid: Yes No