Santa Clara University

Last Name*

First Name*

Date of Birth (DAY)*

Date of Birth (MONTH)*

Date of Birth (YEAR)*

Place of Birth (CITY, STATE)*

Permanent Address (ADDRESS, CITY, STATE, ZIP)*

E-mail*

Program-Location*

Term Abroad*

Your arrival date at the program location:*

Your arrival time at the program location (remember to specify AM or PM)*

The airline that brings you to your final destination:*

The flight number:*

The city and airport you depart from in order to get to your final destination:*

Name of final arrival city and airport:*

If you will not be arriving at your program destination by plane, please specify your arrival details here:

Please list your departure date, if you know, once the program ends.

If you have any addtional comments regarding your travel, please list them here.