LEGAL NAME
Last
First
Middle
SOCIAL SECURITY #
000-00-0000 (for U.S. citizens)
MAILING ADDRESS
STREET
STREET
CITY
STATE/PROVINCE
Not Available Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
POST CODE
COUNTRY
Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria (Rakousko) Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria (Bulharsko) Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China (Čína) Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) (Chorvatsko) Cuba Cyprus Czech Republic Czechoslovakia (former) Denmark (Dánsko) Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland (Finsko) France France (Francie) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia (Gruzie) Germany (Německo) Ghana Gibraltar Great Britain (UK) (Velká Británie) Greece (Řecko) Greenland (Island) Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary (Maďarsko) Iceland (Island) India Indonesia Iran Iraq Ireland (Irsko) Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) (Severní Korea) Korea (South) (Jižní Korea) Kuwait Kyrgyzstan Laos Latvia(Litva) Lebanon Lesotho Liberia Libya Liechtenstein Lithuania (Lotyšsko) Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Holandsko) Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) (Nový Zéland) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway (Norsko) Oman Other Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland (Polsko) Portugal Puerto Rico Qatar Reunion Romania (Rumunsko) Russian Federation (Rusko) Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic (Slovensko) Slovenia (Slovinsko) Solomon Islands Somalia South Africa (Jižní Afrika) Spain (Španělsko) Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden (Švédsko) Switzerland (Švýcarsko) Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey (Turkiye) Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Velká Británie) United States (USA) Uruguay US Minor Outlying Islands USSR (former) (SSSR) Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
TELEPHONE
(please include area code: 000-000-0000)
E-MAIL
PERMANENT ADDRESS
STREET
STREET
CITY
STATE/PROVINCE
Not Available Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
POST CODE
COUNTRY
Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria (Rakousko) Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria (Bulharsko) Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China (Čína) Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) (Chorvatsko) Cuba Cyprus Czech Republic Czechoslovakia (former) Denmark (Dánsko) Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland (Finsko) France France (Francie) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia (Gruzie) Germany (Německo) Ghana Gibraltar Great Britain (UK) (Velká Británie) Greece (Řecko) Greenland (Island) Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary (Maďarsko) Iceland (Island) India Indonesia Iran Iraq Ireland (Irsko) Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) (Severní Korea) Korea (South) (Jižní Korea) Kuwait Kyrgyzstan Laos Latvia(Litva) Lebanon Lesotho Liberia Libya Liechtenstein Lithuania (Lotyšsko) Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Holandsko) Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) (Nový Zéland) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway (Norsko) Oman Other Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland (Polsko) Portugal Puerto Rico Qatar Reunion Romania (Rumunsko) Russian Federation (Rusko) Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic (Slovensko) Slovenia (Slovinsko) Solomon Islands Somalia South Africa (Jižní Afrika) Spain (Španělsko) Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden (Švédsko) Switzerland (Švýcarsko) Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey (Turkiye) Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Velká Británie) United States (USA) Uruguay US Minor Outlying Islands USSR (former) (SSSR) Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
TELEPHONE
(please include area code: 000-000-0000)
DATE OF BIRTH
MM/DD/YYYY optional
AGE
optional
SEX
Male Female optional
HOUSING
Yes - I will need AMDA Student Housing while enrolled in the BFA program
No - I will NOT need AMDA Student Housing while enrolled in the BFA program
DISCIPLINARY ACTION
Have you ever been found responsible for a disciplinary violation at a post-secondary institution, whether related to academic
misconduct or behavioral misconduct that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution?
Yes No
If yes, please explain:
Have you ever been convicted of a misdemeanor, felony or other crime?
Yes No
If yes, please explain:
CITIZENSHIP
I am a U.S Citizen
I am a U.S permanent resident
I am an international student
Country of Birth: Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria (Rakousko) Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria (Bulharsko) Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China (Čína) Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) (Chorvatsko) Cuba Cyprus Czech Republic Czechoslovakia (former) Denmark (Dánsko) Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland (Finsko) France France (Francie) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia (Gruzie) Germany (Německo) Ghana Gibraltar Great Britain (UK) (Velká Británie) Greece (Řecko) Greenland (Island) Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary (Maďarsko) Iceland (Island) India Indonesia Iran Iraq Ireland (Irsko) Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) (Severní Korea) Korea (South) (Jižní Korea) Kuwait Kyrgyzstan Laos Latvia(Litva) Lebanon Lesotho Liberia Libya Liechtenstein Lithuania (Lotyšsko) Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Holandsko) Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) (Nový Zéland) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway (Norsko) Oman Other Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland (Polsko) Portugal Puerto Rico Qatar Reunion Romania (Rumunsko) Russian Federation (Rusko) Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic (Slovensko) Slovenia (Slovinsko) Solomon Islands Somalia South Africa (Jižní Afrika) Spain (Španělsko) Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden (Švédsko) Switzerland (Švýcarsko) Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey (Turkiye) Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Velká Británie) United States (USA) Uruguay US Minor Outlying Islands USSR (former) (SSSR) Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Country of Citizenship: Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria (Rakousko) Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria (Bulharsko) Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China (Čína) Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) (Chorvatsko) Cuba Cyprus Czech Republic Czechoslovakia (former) Denmark (Dánsko) Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland (Finsko) France France (Francie) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia (Gruzie) Germany (Německo) Ghana Gibraltar Great Britain (UK) (Velká Británie) Greece (Řecko) Greenland (Island) Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary (Maďarsko) Iceland (Island) India Indonesia Iran Iraq Ireland (Irsko) Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) (Severní Korea) Korea (South) (Jižní Korea) Kuwait Kyrgyzstan Laos Latvia(Litva) Lebanon Lesotho Liberia Libya Liechtenstein Lithuania (Lotyšsko) Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands (Holandsko) Netherlands Antilles Neutral Zone New Caledonia New Zealand (Aotearoa) (Nový Zéland) Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway (Norsko) Oman Other Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland (Polsko) Portugal Puerto Rico Qatar Reunion Romania (Rumunsko) Russian Federation (Rusko) Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic (Slovensko) Slovenia (Slovinsko) Solomon Islands Somalia South Africa (Jižní Afrika) Spain (Španělsko) Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden (Švédsko) Switzerland (Švýcarsko) Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey (Turkiye) Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Velká Británie) United States (USA) Uruguay US Minor Outlying Islands USSR (former) (SSSR) Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
LANGUAGE
First language, if other than English:
Primary language spoken at home: Optional
INTERNATIONAL STUDENT
If you are an international student, please answer the following:
Did you apply for OPT (Optional Practical Training) during your 4th semester at AMDA:
Yes No
If yes, what were/are the dates of your OPT?
From Month/Year To Month/Year
Privacy Statement:
The following information is required for state and federal reporting. Disclosure is optional.
Please check one of the following that best describes your ethnic background:
Nonresident alien
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Two or more races