INTERNATIONAL STUDENT

APPLICATION

ADMISSION
Thank you for your interest in Chabot College. To attend Chabot College, you must submit a number of
documents in order to be considered for admission to the International Student Program. Attached is a
checklist of all necessary forms to be submitted. Once the college has received the required documents,
you will promptly be advised of your admission status. If you are accepted to Chabot College, a Certificate
of Eligibility for Non-Immigrant (F-1) Student Status (I-20) will be issued to you along with a letter of
acceptance to Chabot College.

If you have further questions, please contact this office directly.

Dolly Balangitao, DSO, Coordinator

International Student Program
Phone: +1.510.723.6715

Fax: +1.510.723.7510
E-mail: [email protected]
Website: www.chabotcollege.edu/international

APPLICATION DEADLINES
We accept applications on an ongoing basis, subject to class space availability. These are our
deadlines:

Fall Semester June 1

Spring Semester November 1

Postal mail the completed application materials to the following address:

International Student Program

Chabot College
25555 Hesperian Blvd
Hayward, CA 94545
USA
 CHECKLIST OF REQUIRED MATERIALS

All forms, information, and documentation must be submitted before your application can be evaluated. Please
use this checklist to verify that the following forms are being submitted along with your application. Thank you.

Chabot College standard Application for Admission completed either paper form
 included in this packet OR completed electronically online @
www.chabotcollege.edu/admissions/apply

$100.00 Non-Refundable Application Fee

 (check or money order drawn against a U.S. bank, or credit/ debit card using the
“Application Fee Payment by Credit/ Debit Card Form”)

 International Student Application

 Certificate of Financial Responsibility indicating Self or Sponsor(s)’ Support

 Bank Certification/Verification of Funds (dated within 3 months)

TOEFL Score (61+ iBT, 173+ CBT or 500+ PBT), IELTS Academic Score of 5.5,
 iTEP with a minimum level 5, OR completion of the ELS 109 course from an ELS
Language Centers program.

 Read carefully and sign the attached Student Contract.

 Proof of Medical Insurance

High School Diploma or Transcript (minimum 12 years of formal education required)
 and/or University Transcript(s) (All must be translated into English by a certified
translation service.)

 Statement of Purpose Essay

 Identification Photograph (1 copy)

 Test of Tuberculosis
Students transferring from another U.S. school must also provide the following:

 Official Transcript from previous school

 Copy of prior I-20(s), pages 1 and 2, Passport (biographical page and entry stamp, Visa
International Student Program
Postal mail completed application to: Chabot College
25555 Hesperian Blvd
Hayward, CA 94545
USA
 INTERNATIONAL STUDENT APPLICATION
The following information is required for issuance of the I-20AB/ID document and must be correct. Please type or
print legibly in ink. Complete all sections of this application and return it with all other required documents.

Name: _______________________ ______________________ ____________________

(as it appears on passport) Last (Family) First (Given) Middle
Date of Birth: _____/_____/_____  Male  Female
Month Day Year
Country of Birth: ___________________________ Country of Citizenship: ________________________

I am applying for the following semester:  Fall  Spring Year 20__

Do you have any dependents accompanying you to the U.S.?  Yes  No.
If yes, please provide your dependents’ full name(s), birth date, gender, relationship, country of birth, and
country of citizenship on a separate page.

STUDENT’S PERMANENT (HOME COUNTRY) INFORMATION (Required by U.S. Immigration.

Agents: do not post your information here.)
Address: ___________________________________________________
___________________________________________________
City:________________________________
State/Province:_______________________
Postal Code:_________________________
Country:____________________________
Telephone: (___)_____________ Fax: (___)_____________ Email: ______________________

MAILING ADDRESS (If different from permanent above. This is where your acceptance package will
be sent. If using an agent, this is where agent’s mailing address is posted.)
Address:___________________________________________________
___________________________________________________
City:_____________________________________
State/Province:____________________________
Postal Code:______________________________
Country:_________________________________

Are you currently in the United States?  Yes  No

If yes, Type of Visa__________ Visa/Status Expiration Date: ______/______/_____
When did you arrive in the United States? _____/_______/_______ Month Day Year
Month Day Year
If F-1 visa transfer student, what is your last date of attendance at your current school? / /
If you plan to travel outside the U.S. before Chabot begins, what is your departure date?___/____/__
U.S. Address (required for F-1 transfer students)
Street __________________________________
City:____________________________________
State/Province:___________________________
Postal Code______________________________
U.S. Phone ______________________ U.S. Fax ________________________
Have you attended Chabot College before?  Yes  No
If Yes, what is your Chabot College Student ID number? _______________
ENGLISH LANGUAGE PROFICIENCY IS REQUIRED PRIOR TO APPLYING
Chabot College will accept TOEFL Score (61+ iBT, 173 CBT or 500 PBT), IELTS Academic Score of 5.5
and above.

Have you taken the TOEFL / IELTS / iTEP?  Yes  No

Your TOEFL / IELTS / iTEP score: _____________________ Date test was taken: _______________

Please submit your TOEFL / IELTS score to Chabot College. Our TOEFL Institution Code is 4725.

Chabot College will accept completion of the ELS 109 course from any ELS Language Centers program.

Are you currently enrolled in an English language program, college, or university in the United States?
 Yes  No

If yes, what is the name of your school? ____________________________________

Upon arrival at the College, all International students will be tested for English and Math proficiency in order
to be placed in the appropriate level of courses.

ACADEMIC INTENT

What is your intended field of study (major)? ___________________________________________

(Selecting a major is necessary in order to prepare the I-20 form)

What is your educational goal at Chabot College?

 Associate degree (2 yr. degree)

 Transfer to a 4 year college to earn a Bachelor’s degree (4 yr. degree)

How did you first hear about Chabot College? Please check one
 Internet
 Friend/ relative recommended
 Overseas recruiting educational fair (AACC)
 Study Abroad publication
 Studying in America (www.studyoverseas.com) (S&R Media)
 International Education Service
 Other ______________________________________

CERTIFYING STATEMENT
I hereby certify that all information provided on this application is true and correct. I understand the
presentation of false information or failure to comply with Chabot College’s admission and registration
procedures may result in my dismissal without refund of any fees paid.

Name (print) ____________________________________________________________________________

________________________________________________________ _____________________________
Signature Date
 CERTIFICATE OF FINANCIAL RESPONSIBILITY

Should you be accepted as a student at Chabot College and if you will not be living with a local U.S.
sponsor, you are required to provide bank statements verifying a minimum of $20,644 USD is available for
your first academic year (9 months). The funds do not have to be held in a U.S. bank. This office is able to
calculate the currency conversion. Please request 2 copies of verification of funds. Submit 1 copy to
Chabot College. Keep 1 copy for your visa appointment and U.S. Immigration. If the funds are not yours,
please have your sponsor(s) complete the Sponsor’s Affidavit section below.
OR
Students funded by a U.S. sponsor and going to the U.S. Embassy in their home country to obtain their F-1
visas are required to have their U.S. sponsor send them a completed U..S. Immigration Form I-134 Affidavit
of Support. This form can be downloaded off the USCIS website @ http://www.uscis.gov/forms Please
have your U.S. sponsor request 2 copies of verification of funds totaling at least $20,644 USD. Submit 1
copy to Chabot College. Keep 1 copy to submit with the Form I-134 at your visa appointment.
OR
If you have a local U.S. sponsor providing free room, board and living expenses while someone from your
home country pays for your tuition and textbooks. Have each sponsor complete the Sponsor’s Affidavit
section below. U.S. sponsors who are either U.S. Citizens or Permanent Residents would still need to
complete the immigration Form I-134 Affidavit of Support and attach documentation proving their financial
ability to provide room and board and living expenses. Most sponsors attach a copy of their most recent tax
return. We will then require a separate bank statement verifying the sum of $8,644 USD or its equivalence
is available for your tuition, textbooks and medical insurance for the first academic year and who the person
is providing that funding. That proof of funding can be provided by your local U.S. sponsor or from another
source.

SPONSOR’S AFFIDAVIT (complete one form for each sponsor)

I, , agree to act as sponsor for

___________________________________________ (Name of Student)

as an international student at Chabot College for the year beginning __________________.

As sponsor, I agree to guarantee all of the following checked expenses for the school year. (Check all that
apply to you):

Tuition ($6984)
Room and board ($12,000)
Textbooks ($1300)
Medical Insurance Coverage ($360)
Transportation to and from the campus and the student’s residence.
Return transportation to the student’s country of residence, should this return become necessary
at any time prior to the finish of the student’s educational program at Chabot College.

Signed: _____________________________________________ Date: ________________________

Relationship to Student: ________________________________
Sponsor’s Name: ______________________________
Address: ______________________________ Email address:
______________________________ Telephone: _______________________
Rev 2/17 F-1 Certificate of Financial Responsibility Sponsors Affidavit
 INTERNATIONAL STUDENT AGREEMENT
If I am admitted as a student at Chabot College:

 I must attend the 1-day International Student Orientation

 I must enroll in, attend and complete (no “W” withdrawals) at least 12 units (full-time) of class at
Chabot College each Fall and Spring semester (Summer optional)

 I must not enroll in more than 3 units of a distance education (online) course per semester.

 I must have a current Student Educational Plan (SEP) on file and meet a Counselor once a
semester.

 I will maintain a cumulative grade point average (GPA) of 2.0 “C”.

 I will take an assessment test to demonstrate my proficiency in the use of the English language and
will enroll in any classes suggested by the College to improve my English proficiency.

 My beginning math classes will be determined by a placement examination.

 I must pay all tuition and fees each semester according to College regulations.

 I must be covered by an acceptable medical insurance policy and provide the International Student
Program office with proof of insurance within 10 working days of the beginning of the semester.

 I must limit on campus employment to no more than 20 hours per week while school is in session in
accordance with U.S. Department of Homeland Security (DHS) regulations.

 I may not work off-campus without authorization from the U.S. Department of Homeland Security
(DHS).

 I must notify the International Student Program Office of any changes in address within 10 days in
accordance with U.S. Department of Homeland Security (DHS) regulations. The Office will then
update my SEVIS record.

I understand that failure to comply with any of the Chabot College Student Conduct Policy and
regulations as stated in the College Catalog may result in a hold placed on my student records or
dismissal from the College. I acknowledge that it is my responsibility to understand and follow the DHS
F-1 student regulations. I also understand that if I fail to meet the DHS regulations as they pertain to
maintaining my F-1 student visa status, Chabot College is obligated to notify the U.S. Immigration and
Customs Enforcement (ICE) branch of DHS via updating my SEVIS record. I understand that this could
result in deportation from and future exclusion to the United States.

____________________________________ _______________________
Signature Date
 TUBERCULOSIS TEST
(To be completed and signed by Physician)

TUBERCULOSIS (TB) TEST

Medical Examination of: _______________________________________________________________

Name of Applicant

Date of TB skin test (must be current): _____________________________

Result of TB test: Positive  Negative 

If TB test is positive, x-ray is required.

Date of x-ray: ______________________________________

Results of x-ray: Positive  Negative 

It is strongly recommended that students provide proof of the following Immunizations:

Tetanus Toxoid _____

Polio Vaccine _____

Rubella _____

_______________________________________________________ ___________________________
Physician’s Signature Date

____________________________________________________ ______________________________
Physician’s Name (please print) Telephone Number

_______________________________________________________________________________________
Address – Street

____________________________________________________________________________________
City, State and Zip

_____________________________________________________________________________________
State License Number

International Student Program

Return this form with application, or postal mail to: Chabot College
25555 Hesperian Blvd
Hayward, CA 94545
USA
 MEDICAL INSURANCE AFFIDAVIT
All international students are required to purchase medical insurance. Coverage must include
repatriation and medical evacuation. FAILURE TO DO SO MAY RESULT IN DISMISSAL FROM THE
COLLEGE.

 I hereby submit the attached evidence of health and medical insurance which I have purchased. This
insurance will cover the usual and normal costs that might incur due to accident and/or illness while in
attendance at Chabot College.

Name of Insurance Carrier: __________________________________________________________

Policy Number or Identification: ___________________________________________________

Policy Expiration Date: ______________________________________________________________

Address of Insurance Carrier:

_____________________________________________________________
(Please attach a copy of your medical card or policy)

If you do not have your medical insurance yet, check the box below:

 I hereby agree to purchase health and medical insurance before the end of the second
week of classes and maintain medical coverage during my entire period of attendance at
Chabot College. I will present evidence of continuous coverage to the International Student
Office. I UNDERSTAND THAT FAILURE TO DO SO MAY RESULT IN DISMISSAL FROM THE
COLLEGE.

_______________________________________
Student’s name – please print

_______________________________________
Student’s signature
 PERSONAL ESSAY - STATEMENT OF PURPOSE
Please write a brief statement, written in your own handwriting, describing:
A) your reasons for wanting to study in the United States,
B) your future academic and career goals, and
C) how you became interested in Chabot College.
Use additional sheets of paper if necessary.

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 International Student Program
25555 Hesperian Boulevard
Hayward, California 94545 USA
[email protected]
Fax: +1.510.723.7510

Chabot College International Student Program

Fee Payment by Credit Card Form
Name:
Exactly as it appears __________________________________________________
on the credit card
Address: ___________________________________________
The address on
record with the
credit card company

Credit Card Type (check one): □Visa □ MasterCard

Credit Card Number:

・・・・-・・・・-・・・・-・・・・
Expiration Date: ・・-・・
Credit Card 3 Digit Security code: ・・・
This is the 3-digit code found on the back of your card. It is the last 3 digits located in the signature
section.
Amount to be Charged: USD$ ____________________

Signature of Credit Card holder: ___________________________________

Date: ___________________ Name of Student:

Please postal mail or email as an attachment or fax this form to
Chabot College International Student Program