C A L I F O R N I A S T A T E P O L Y T E C H N I C U N I V E R S I T Y , P O M O N A
Global Education Institute
College of the Extended University
APPLICATION FORM
Program: Student Innovation & Entrepreneurship Program (SIED)
Term: Winter 2018
Application Due: December 15, 2017
1 PERSONAL INFORMATION
Please type or clearly print your name exactly as it appears on your passport. Submit a copy of your
passport information page.
Last Name (family name):____________________
First Name (given name):____________________
Gender: Male Female
Date of Birth: _______/_____/_________
Month Day Year
Country of Birth: ___________________________
Country of Citizenship: ______________________
Native Language: __________________________
Name of College/University: _________________
_________________________________________
Year: 1st 2nd 3rd 4th Graduate
Major: ___________________________________
Phone Number: ____________________________
Cell Phone: _______________________________
Email: ___________________________________
Social media that you use most often (WeChat,
WhatsApp, Line, etc):
_________________________________________
ID: ______________________________________
Mailing Address:
Name: ___________________________________
Street Address: ____________________________
_________________________________________
City: _____________State/Province: ___________
Zip Code: __________ Country: ______________
Phone: ___________________________________
Home Address (leave blank if same as mailing address):
Street Address: ____________________________
_________________________________________
City: _____________State/Province: ___________
Zip Code: __________ Country: ______________
Permanent Telephone: ______________________
3 FINANCIAL INFORMATION
For visa interview purposes, we recommend that you prepare a copy of a bank-certified financial statement on official bank letterhead to prove that you have sufficient funds to cover tuition and living expenses during the program study period. All funds must be stated in U.S. dollars, and the statement must be dated less than six months before the date the applications is received.
Source of Financial Support (minimum $6,000):
Parent/family member Friend Self Other
Contact Information of Financial Sponsor:
Name: ___________________________________
Street Address: ____________________________
_________________________________________
City: _____________State/Province: ___________
Zip code: __________ Country: _______________
Phone: ___________________________________
Declaration of Financial Sponsorship:
I certify that I will assume full financial responsibility (including educational and living expenses) for the applicant while he/ she is enrolled in the Student Innovation &
Please note: Date and prices are subject to change with prior notice.
THE CALIFORNIA STATE UNIVERSITY Bakersfield, Channel Islands, Chico, Dominguez Hills, East Bay, Fresno, Fullerton, Humboldt, Long Beach, Los Angeles, Maritime Academy, Monterey Bay, Northridge, Pomona, Sacramento, San Bernardino, San Diego, San Francisco, San Jose, San Luis Obispo, San Marcos, Sonoma, Stanislaus
C A L I F O R N I A S T A T E P O L Y T E C H N I C U N I V E R S I T Y , P O M O N A
Global Education Institute
College of the Extended University
Entrepreneurship Program at California State
Polytechnic University, Pomona.
Signature: __________________ Date: _________
Relationship to Student: _____________________
(example: mother/uncle/friend/etc.)
4 PAYMENT PROCEDURE
Your program fee payment of $2,980 is due by
January 18, 2018. You can choose any payment
type below:
• Online transfer (Flywire): https://www.flywire.com/pay/ceu
• Cashier’s check or money order payable to Cal Poly Pomona Foundation, Inc.
• Wire Transfer (a $30 transaction fee will apply)
5 SIGNATURE
I certify that the information on this entire form is
correct to the best of my knowledge. I agree to pay
the required program fee.
Student’s Signature: ________________________
Date: ____________________________________
6 SUBMISSION INFORMATION
Please submit the completed Application Form
and a copy of your passport information page
by email to:
Vivienne Shen, Ed.D.
Program Developer/Manager
Global Education Institute
College of the Extended University
California State Polytechnic University, Pomona
Phone: +1 (909) 869-2256
Fax: +1 (909) 869-5077
Email: xshen@cpp.edu
3801 W Temple Ave., Bldg. 220A-203
Pomona, CA 91768
USA
Please note: Date and prices are subject to change with prior notice.
THE CALIFORNIA STATE UNIVERSITY Bakersfield, Channel Islands, Chico, Dominguez Hills, East Bay, Fresno, Fullerton, Humboldt, Long Beach, Los Angeles, Maritime Academy, Monterey Bay, Northridge, Pomona, Sacramento, San Bernardino, San Diego, San Francisco, San Jose, San Luis Obispo, San Marcos, Sonoma, Stanislaus
