INTERNATIONAL STUDENT
EDUCATIONAL HISTORY FORM
PLEASE PRINT CLEARLY. Return this form to Broome Community College, Admissions Office, PO Box 1017, Binghamton, NY 13902 U.S.A
NAME: ____________________________________________,_________________________________________________
(Family/Last Name) (Given/First Name)
E-MAIL: ____________________________________________________________________________________________
PERSONAL DATA:
Date of Birth: ____/____/____ Country of Birth: __________________________ Country of Citizenship: ___________________________ Male Female
Month / Day / Year
EDUCATIONAL AND CAREER PLANS: Please indicate the program of study you wish to enroll in: ______________________________________________
Please explain your educational and career plans: ________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
ENGLISH LANGUAGE PROFICIENCY: If your native language is not English, you must demonstrate acceptable English language proficiency for your
application to be considered for admission to the College. This requirement can be met by (1) submitting an official TOEFL score of 400 or better or (2) submitting official
academic records showing the successful completion of at least four years of English language study at the secondary school or higher level. TOEFL is not required for
admission; however, if you have taken the Test of English as a Foreign Language (TOEFL), please provide a copy of the results. Below please indicate the number of
years you studied English at each educational level:
Secondary School _________ College/University _________ Other (Please explain) _____________________________________________________________
Please list below in chronological order all secondary schools, institutes, colleges and universities you attended.
Instructions:
Column 1 - Write the name of the secondary school, institute, college or university you attended (Please indicate any school you are presently attending).
Column 2 - Address of secondary school, institute, college or university attended, including city and country.
Column 3 - Indicate in chronological order the dates (month and year) of each school you attended.
Column 4 - Write the educational level of each school you attended, using the terminology of the country’s educational system. (Example: secondary school, high school, institute, ecole secondaire, gymnasium)
Column 5 – Write the name of any certificates, diplomas or degrees earned or external examinations passed, using the terminology of the country's educational system. (Example: (O or A-level), Bachiller,
CXC, WASC, Baccalaureat, Maturita, etc.) Please also indicate the date academic credential was received.
1) Name of Secondary School, 2) Address (including city and 3) Dates of 4) Level of 5) Name of Certificate, Diploma or Degree
Institute, College, University country) Attendance Education Earned (including any External Examinations
passed) and Date Received
Please indicate any additional information about your educational background or academic achievements:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I agree to become familiar with and abide by all the rules and regulations of Broome Community College and understand that an y falsification or deliberate omission on
this application is sufficient reason for refusal of admission or subsequent dismissal. In addition, I understand that my signature and dating of t his application will be
considered a written consent for record(s) release in conformance with 20USC Section 123G, the Family Educational and Privacy Rights Act of 1974.
Applicant’s Signature: _____________________________________________________________Date: __________________
All information supplied to complete this application will be kept confidential according to the provisions of the Family Educational and Privacy Rights Act of 1974. The Personal Privacy Protection Law requires this notice to be provided when collecting personal
information from individuals: The information on this admissions application will be used by Broome Community College to evaluate your request for admission. This authority to request information is found in Section 355 (2)(1) of the Education Law. This application
information will be maintained in the Office of the Registrar. The official responsibility for the maintenance of this information is the Registrar at Broome Community College, Box 1017, Binghamton, NY 13902 USA
Broome Community College does not discriminate on the basis of race, sex, color, religion, age, national origin, disability, marital status, sexual orientation, or status as a disabled veteran or veteran of the Vietnam era in the recruitment or education of
students; the recruitment and employment of faculty and staff; or the operation of any of its programs or activities. Where relevant, state and federal laws apply.
