NOVA
Community College
Northern Virginia
Form 125-043 Rev. 03/11 Pg. 1 of 2
F-1 I-20 Application
This form along with the other forms and documents required for the I-20 should be mailed or taken directly to: Office of International Student Services 7630 Little River Turnpike Suite 815 Annandale, VA 22003 Please complete both sides of the form. Name:
Family Name First Name Middle Name
NOVA Student ID #: Date of Birth: Country of Birth: Are you currently in the United States? Yes No
Month/DaylYear
Gender (male/female) Country of Citizenship: If yes, what is your visa status?
Permanent Address Outside U.S. (This information is required for I-20.): Address: City: Province: Postal Code: Country: U.S. Address (if known): Street: City: State: E-mail address: Please check Your e-mail regularly. Zip Code: @
Student's Telephone Number in Virginia, Maryland or D.C. (if any) Check only one of the following options: I will pick up my I-20. (OISS will call the student when the I-20 is ready.) Please send mv I-20 to mv U.S. address. Please send my I-20 to my address outside the U.S. (please make sure your address is written very clearly) Please give my I-20 to the following person: Name: Address: Phone Number: Cell phone number:
Form 125-043 Pg. 2 of 2
Student application information (Please check the statements that apply to your application.) I plan to attend the Intensive English Program only. I plan to attend the Intensive English Program and continue my studies for an Associate degree, after meeting the English language requirement. I plan to pursue an Associate degree in the following major: In which semester do you want to begin your studies at NOVA? Spring Summer
Fall
Evidence of English proficiency ( if you are applying to begin in an Associate degree program): (Check one) English is one of my primary languages I have studied at a U.S. college or university whose credits are accepted by NOVA and have completed freshman English composition with a grade of C or higher. (include transcript) I have studied an ELS Language Center and passed Level 112. I have taken the English placement test at NOVA and received a score of Level 4 or higher. I have taken one of the following tests within the past two years: (official score must be sent to NOVA) Date: 0 TOEFL: PBT TOEFL: CBT Date: 0 TOEFL: IBT Date: 0 0 IELTS Date: PTE - Academic 0 Date: 0 SAT: Critical Reading Date: Which campus of NOVA do you wish to attend? Alexandria Annandale Loudoun Manassas Medical Education Campus - Springfield Woodbridge
Information about Dependents: I plan to come alone. I will be accompanied by the following dependents. Please make sure that the names are written very clearly. (Dependents can only include spouse and/or children): Name: Date of Birth: Country of Birth: Relationship: Gender: spouse child male female
Month/Day/Year
Country of Citizenship:
Name: Date of Birth: Country of Birth:
Relationship: Gender:
spouse child female male
Month/Day/Year
Country of Citizenship:
Name: Date of Birth: Country of Birth: / /
Month/Day/Year
Relationship: Gender:
spouse female male
child
Country of Citizenship: (Please make additional copies if you have more dependents)
I am requesting Northern Virginia Community College to issue an I-20 form, I understand that by using this form to enter the U.S. or change to F-1 status, I will be expected to study at NOVA for at least one semester. I certify that all the information included with this request is true to the best of my knowledge. Signature:
Student's Signature
Date:
