Application

Name *

• First
• Last

Sex *

• Male
• Female

Date of birth *

Permanent Address *

• Street Line 1
• Street Line 2

• City
• State/Province/Region Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Non-U.S.

• Zip/Postal code
• Country

Local Address

• Street Line 1
• Street Line 2

• City
• State/Province/Region Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Non-U.S.

• Zip/Postal code
• Country

Leave blank if same as permanent address.

Email Address *

Phone *

• (###)
• ###
• ####

Citizenship status * Select United States citizen Immigrant, a permanent resident of another country Non-immigrant, citizen of another country

If immigrant or non-immigrant is selected, please fill out the country box below.

If immigrant or non-immigrant is selected above, please list the country where you are a permanent resident or citizen of.

Current university *

City and state of current university *

e.g. Cincinnati, Ohio

First month and year attended *

e.g. August 2012

Last month and year attended

e.g. December 2012

Currently enrolled? *

• Yes
• No

Xavier Banner ID

Transcript

If you are not a current Xavier University student please mail an official transcript with the other required forms to Xavier University Department of Sports Studies, Attention: Peggy Eichhold, 3800 Victory Parkway, Cincinnati, Ohio 45207-6312. If you have an electronic copy, please submit that file via a PDF document.

Current status * Select Freshman Sophomore Junior Senior Graduate Student

Major field of study *

GPA *

Emergency contact name *

• First
• Last

Relationship *

Emergency contact address *

• Street Line 1
• Street Line 2

• City
• State/Province/Region Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Non-U.S.

• Zip/Postal code
• Country

Emergency contact email address

Emergency contact phone *

• (###)
• ###
• ####

I certify that the information in this application is accurate and true. I authorize Xavier University’s International Education Center (CIE) to access my academic records and to contact appropriate personnel to verify that I am under no disciplinary action or have judicial cases pending against me. *

• By checking the box, you agree to the above statement.