SUPPLEMENTAL INFOMRATION FORM
Complete only if you have attended another high school, college or university in the U.S.A. on an F-1 VISA.

Please fill in the following information and send or give it to the International Student Advisor at the U.S. institution you currently attend or did attend.  Your advisor should send the completed document to any of the following: 
Andrea Kemper, Admissions, Mineral Area College, P.O. Box 1000, Park Hills, MO 63601-1000, akemper@mineralarea.edu or fax to 573-518-2260.
This is required for your application to Mineral Area College and will be treated as confidential. Contact 573-518-2260 with any questions.
 
Name________________________________________________________________________________________ 
            (First)                                       (Middle)                                          (Last) 
Present Address: 
 
._____________________________________________________________________________________________ 
 Number & Street                        Apt. No.          City                                        State                 Postal Code                    
 
Date of Birth______________________   Country_____________________    Visa Type_____________________ 
             (Month)        (Day)      (Year) 
 
Sex:   Male     Female                Single    Married         If married, is spouse in the U.S.?    Yes    No     
 
First school issuing you an I-20 Form ______________________________________________________ 
 
Address of School: 
 
._____________________________________________________________________________________________ 
 Number & Street                                City                        State                    Postal Code                     Country 

Country issuing your passport _____________________________________________________________________ 

Port of most recent entry into the U.S. ______________________________________________________________ 
 
I hereby request and give my permission for the information below to be released to Mineral Area College. 
 
____________________________________________________    Date___________________________________ 
Applicant’s Signature    
 
***************TO BE COMPLETED BY DESIGNATED SCHOOL OFFICER**************** 
 
Student was in good standing at your institution:    Yes    No 

Dates of attendance at your institution: From ______________________ to _________________________________

Student’s SEVIS number _____________________________ SEVIS release date ____________________________

Release information: Mineral Area College – Campus Code KAN214F10146000                       

I have reviewed the information above and find it to be accurate. 

 _____________________________________________________________________   Date__________________ 
 Please Print:  School Official Name and Title 
 
.____________________________________________________________________________________________________________________ 
 Signature of School Official                           e-mail address                                                       Telephone number 
 
.____________________________________________________________________________________________________________________ 
 School Name                              Address                                     City                  State                  Zip