Office use only:  Acct. # ______
                           Approved ______
                           Date ______
INTERNATIONAL HOUSE
2299 PIEDMONT AVE. BERKELEY, CA 94720-2320
APPLICATION FOR ROOM LICENSE AND BOARD CONTRACT DEFERMENT

Must be submitted with: 1) a non refundable deferment fee (per semester) of US$20.00 and
                                        2) supporting documentation

Name_________________________________________________________________________________

        (Last, first and middle)                                                                                                                                                  (phone number)

Present mailing address________________________________________________________

Home or permanent address____________________________________________________                                                                                                             (Street, number, city, state, zip code, country)

University status: undergraduate______ graduate______ other______

               major_______________________ student registration #______________________

Date of birth____________ Social Security #_________________________

Passport #____________________ Driver's License #________________________ State___________

Type of Visa_____________________ Name of Sponsor_____________________________________

How many additional semesters do you plan to register at this Campus?______

How many additional semesters do you plan to live at International House?______

Are you presently employed?_________ Employer________________________________

Contact person__________________________________ Phone #_____________________

Please give specific reason(s) why you are unable to pay on the scheduled date:

_______________________________________________________________________________

_______________________________________________________________________________

Total amount due US$______________ for__________________ - ____________.
                                                                           (one semester only)                      (Year)

Your plan to make the following payments with income from the following source(s) (Attach supporting documentation):

________________________________________________________________________________________________

________________________________________________________________________________________________

I'm requesting the following deferred payment schedule:

Date Amount Date Amount
       
       
       
       
       
       

Name and address of parent, spouse, nearest relative, sponsor or guardian:

________________________________________________________________________________________________
(Last, first name - relationship)                                                                                                                                                  (phone number)

__________________________________________________________________________________________________________________
(Home address - street, number, city, state, zip code, country)

Who is responsible for your indebtedness?__________________________________________________

What is your principle means of support?__________________________________________________

Do you have a Bank account?__________ Bank name______________________________

Branch ________________________ Account #________________________

Personal references: These should be mature persons who have known you for at least three years. One may be a relative but not a member of your immediate family. None should be connected with the University unless a relative.
Name Address Occupation Relationship
       
       
       

Agreement: The undersigned agrees to the accuracy of the above information and to make deferred payments according to the approved payment schedule. I understand that if my payment cannot be made , I must contact the Cashier's Office prior to my due date, or a US$3.00 per calendar day late fee will be assessed on my account. I understand that there will be a US$15.00 service charge and that late fees will be assessed when payments made by checks are returned unpaid from the Bank to the I-House. I understand that my application for deferment will not be processed if my US$20.00 deferment fee is not included.

Signature of applicant______________________________ Date_____________