Peterson's International Undergraduate Student Survey ACUUS International Student Form

International Undergraduate Student Survey

Advising Center Code:

(Please Note: If your system times out, click here to PRINT PDF SURVEY and return via Mail or Fax.)

Note: The fields that are required are marked with a red asterisk (*)

KEY USING ENGLISH LETTERS ONLY

Key your name and complete address below EXACTLY as if you were mailing a letter to yourself.

Sample Name and Mailing Address:

Belinda Miller
(given name) / (family/last name)
28-20-8, Pandan Heights Condo
Pandan Perdana
55300 Kuala Lumpur
Malaysia (country selected from list)

Given/First Name:*

Family/Last Name:*

Mailing Address:*

(Include street address/box, city, state/province, and postal codes as if you were mailing a letter to yourself, including all of the information an American college or university needs to mail information to you. See example above.)

Number/Street or Post Office Box Number:*

Address Line2:
[if needed]

Address Line3:
[if needed]

City, State/Province,&
Postal Codes:*

Country:*

Phone (include country code):

Fax (include country code):

E-mail Address (in full):

Date of Birth:

(DD-MM-YYYY)

Gender:

Male	Female	Clear choices

Answer all the following questions as completely as possible.

1. Country of citizenship:* Stateless

2. I want to enter a college or university in academic year:*

I am interested in midyear admission

3. I am interested in the following field(s) of study (major) or I am undecided (select 1-3 fields of study or Undecided):*

Field of study:

or:
Undecided

4. I will be sponsored by:

Family/Myself

Government

Neither

Private Organization Other

I/my sponsor will be able to contribute toward the total cost of my education (tuition & cost of living) each year:

5. I would prefer to attend (select one):*

2-year institution (first 2 years - associate degree)	4-year institution (bachelor's degree)	I have no preference

6. I am interested in attending a college or university in the following regions of the United States or I have no preference (select 1?4 regions or No Preference):*

No Preference

Middle Atlantic (Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia, West Virginia)

Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin)

New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont)

Southeast (Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee)

Southwest (Arkansas, New Mexico, Oklahoma, Texas)

West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming)

7. I took the TOEFL in: / (MM/YYYY)

Please select only one test format below and include your score in the space provided:
Paper & Pencil: (range 310 to 677)

Computer-Based Test: (range 40 to 300)

Internet-Based Test: (range 0 to 120)

I will take the TOEFL in: / (MM/YYYY)

8. I took the SAT in: / (MM/YYYY)

If reporting scores, please include both SAT Verbal\Critical Reading and Math scores.

My SAT Verbal or Critical Reading Score was (range 200 to 800)
My SAT Math Score was (range 200 to 800)
My SAT Writing Score was (range 200 to 800)

I will take the SAT in:
/ (MM/YYYY)

9. I would like information on intensive English language programs in the United States:

Yes	No	Clear choices

10. The full name and location of my secondary/high school is:

School Name
Country

11. I will finish/have finished secondary/high school in: (YYYY)

12. The certificate I will receive at the end of my secondary/high school studies is called:

13. My average grade in my last year of study was:

14. For students who have attended one or more years at a university:

I have completed years of university-level education at:

name of university

15. Check here to receive information from Peterson?s and our partners about products and services related to studying in the United States.

Please review your contact information and educational profile. Once you submit your student profile, you will not be able to access it again.

*You must use this button to complete your survey and register with our network.