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Information to be Used for I-20 Form: 1. Family Name (surname)_______________________________________________ First (given) name (not middle name)__________________________________ Country of Birth___________________ Date of Birth____________________ Country of Citizenship______________________________________________ Admission Number (if known)_______________________________________ 2. Foreign Address_____________________________________________________ _______________________________________________________________ City State or Providence Country Postal Code 3. U.S. address/sponsor address: ______________________________ ______________________________ ______________________________ U.S. telephone or cell: ________________________ 4. This certificate is issued to the student named above for: ____ ____ ____ ____ ____ Initial attendance at this school Change of status request/initial attendance at this school Continued attendance at this school School transfer from:_______________________________________ Use by dependents entering the United States 5. Level of education the student is pursuing or will pursue in the United States: ____ ____ ____ ____ ____ Associate Bachelor’s Masters Doctorate Language Training 6. The student named above has been accepted for a full course of study at this school majoring in __________________The student is expected to report to the school not later than_____________ and complete studies not later than_________. The normal length of study is __________________________. 7. English proficiency is required: ____ The student has the required English proficiency. ____ The student is not yet proficient, English Instructions will be given at the school.