Student Biodata Form – Fill Out and Use This PDF

Personal Information (Type or print clearly)

Name:

	First		MI		Last
CSU ID#:
Date of Birth:			/		/
			Month	Day	Year
Marital Status:			Single	Gender:	Male
			Married		Female

Will you complete your Peace Corps assignment with your spouse? Yes  No

Name of spouse _____________________________________

Local Address:

Local Phone:

Local Address good through*:

*After this date mailings will be sent	(day/month/year)
to your permanent address

E-mail address you will be using while in the Peace Corps:

Please Note: It is essential that we have an active e-mail address so that we may contact you about your financial or academic status while you are out of the country.

U.S. Address

Name:

Address:

Phone:

Academic Information

Proposed Degree/Home Department:

When you return to CSU, which of the following will you need to complete (check all that apply):  Course Work  Thesis  Professional Paper  Other

Anticipated Graduation: Term		20

Academic Advisor:

Peace Corps Assignment Information

Country Assignment: __________________________________

Program Assignment:  Education and Youth/Community Development  Health and HIV/AIDS  Environment  Business Development/Information Technology  Agriculture

Departure Date: _______________________________________

Close of Service Date: _________________________________

Proposed project title:

(If Peace Corps assignment is unknown, please notify intled@colostate.edu when an assignment has been made)

Continuous Registration and

Technology Fee Information

All graduate students at Colorado State University are required to be continuously registered in the fall and spring semesters throughout the duration of their studies. To maintain your graduate status at CSU, you will therefore be enrolled in continuous registration for each semester of your Peace Corps service. The $150 fee normally charged for continuous registration will be waived if you have completed a fee waiver form for each semester you are abroad. However, a $20 technology fee will be charged to your account for each semester you are abroad. It is possible that this fee may increase during your two years of Peace Corps service. Please make arrangements in advance of your departure to have this fee paid. Please initial where appropriate:

______ I have turned in five signed Continuous Registration

Waiver Fee forms to my department, one for each semester that I will be away.

_______ I have designated a US contact to pay the $20

technology fee on my behalf each semester that I am away and have given consent for OIP to release my finical records to persons responsible for this payment on the following page.

_______ I am enrolling in internship or independent study credit

during my Peace Corps experience and understand that all grades of incomplete turn into an “F” after 1 year.

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student account information;

health information (in the event of a serious mental or physical health condition or emergency and the OIP is contacted by the Peace Corps);

information pertaining to registration for the semester I return to CSU;

disciplinary information;

Peace Corps assignment information.

Departments, please return this form at least 3 weeks prior to the start of classes. For questions, contact:

Karen Gardenier

Peace Corps Master’s International Program

Office of International Programs

Laurel Hall, 1024 Campus Delivery

Fort Collins, Colorado 80523-1024

Tel: (970) 491-0737

Fax: (970) 491-5501

June 2013

intled@colostate.edu

http://www.international.colostate.edu