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Partners in Cross-Cultural Learning - Application Form for Students

Personal Information
First/Given Name:
Last/Family Name:
Date of birth (MM/DD/YY):
Age:
Home Country:
Religion (optional):
Native Language:
Other Language (s) spoken:
Fluency in spoken English: Excellent  Good  Fair  Poor
Gender: Male  Female 
Marital Status: Single  Married  Other 
Will you be staying on campus during vacation periods? Yes  No 
For how many semesters do you intend to be enrolled in SUNY Plattsburgh?
Do you dislike animals/pets, or are you afraid of or allergic to them? Yes  No 
Do you smoke? Yes  No 
If you have any allergies or dietary requirements, please list them:
If you have any medical conditions that your partner should know about, please list them:
Local Contact Information 
Local/Campus Mailing Address:
City:
State/Province:
Zip/Postal Code:
Plattsburgh Phone Number:
Cell Phone Number with area code:  

Best time to reach you:

Morning
Afternoon
 Evening

Email Address (that you check daily):
International Experience
What is the extent of your international experience? (Examples: travel, student host, work abroad, etc.)  
Professional and Recreational Interests
 What is/was your job in your country?  
What is your major at SUNY Plattsburgh?
What are your professional goals?
What hobbies or activities do you enjoy?
Why do you want to be paired with an American PICL partner?
Partnership Requests   

Gender/Marital Status:

Single Male  Single Female Married couple 

No Preference
Age: Younger adults  Older Adults  No Preference
Smoking: Smoker (s)  Non-Smoker (s)  No Preference
Children:

Family with no children  Family with children

No Preference
Please list any additional partner attributes that might be important to you: (religion, smoking, marital status, etc.)
If we cannot meet all of your preferences, will you accept being paired with another partner? Yes  No
 

Thank you for applying!! We will contact you soon.

Questions, Comments, Suggestions?

If you have any questions about the Partners in Cross-Cultural Learning Program at SUNY-Plattsburgh, please contact the PICL Coordinator:

Michelle St. Onge
International Student Services
State University of New York at Plattsburgh
Kehoe Administration Building, Room 209
101 Broad Street
Plattsburgh, New York 12901 USA

Phone: (518) 564-3287
Fax: (518) 564-3292
E-mail: picl@plattsburgh.edu

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