Text Box: UTD PILOT PROGRAM FOR ENROLLING STUDENTS FROM MEXICO P P E S M
THE CENTER FOR U.S. - MEXICO STUDIES (CUSMS) 
SERVICES USE ONLY - VALIDATION
Mexican passport expiration date    
Visa type & expiration date    
CUSMS representative date & signature    
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Text Box: A. GENERAL INFORMATION
UTD STUDENT ID # :       
S.S. NUMBER :       
NAME :                       
(last) (middle) (first)
                       
PERMANENT ADDRESS :                  
  Street & Number City & State  
   
                   
  ZIP Country  
   
   
LOCAL U.S. ADDRESS:                             
  Street & Number City & State  
   
                   
  ZIP Country  
   
   
TELEPHONE NUMBER :      EMAIL ADDRESS :        
       
 
 
Have you attended any other U.S. universities or colleges before July 12, 1991?  Yes No  
   
Have you been awarded this tuiton waiver for Mexican Nationals before? Yes No  
   
Are you transfering from a Texas border university or college? Yes No  
   
  If yes, indicate the last institution attended:            
                       
Text Box: B. PROGRAM INFORMATION
 
       
 
           
  GRADUATE STUDENT UNDERGRADUATE STUDENT  
   
   
MAJOR :        HOURS PER SEMESTER :         
   
   
WHAT SEMESTER ARE YOU APPLYING FOR (check all that you wish to be considered for)  
   
Fall 2002  
Text Box: C. CONTACT INFORMATION
  Spring 2003  
  Summer 2003  
                       
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Text Box: C. FINANCIAL SUPPORT INFORMATION
A. ANNUAL INCOME
[1]  PERSONAL SAVINGS
  BANK OR INSTITUTION     AMOUNT (US DOLLARS)    
     
     
                     
                     
                     
                     
                     
                     
     
                     
SUBTOTAL (US DOLLARS) $ :          
[2]  FINANCIAL AID FROM GOVERNMENT AGENCIES
SUBTOTAL (US DOLLARS) $ :          
[3]  INCOMES
Please list any actual income from job sources, (include any support from UTD source)
  COMPANY       AMOUNT (US DOLLARS)    
     
     
                     
                     
SUBTOTAL (US DOLLARS) $ :          
[4]  OTHER SOURCES
Please add any other resource to count towards the total amount
SUBTOTAL (US DOLLARS) $ :          
TOTAL RESOURCES (US DOLLARS) $ :              
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B. ANNUAL OUTCOMES
NUMBER OF DEPENDANTS :      
ESTIMATED FEE AND TUITION EXPENSES :        
LIVING EXPENSES (IN US DOLLARS) :        
OTHER EXPENSES (INCLUDE DEPENDANT EXPENSES) :        
TOTAL EXPENSES (US DOLLARS, PER SEMESTER) $ :          
Text Box: D. VERIFICATION AND PENALTIES
Text Box: I certify that the above information is correct as to my best understanding. I understand that the information submitted herein will be relied upon by officials of University of Texas in Dallas in determining my status in accordance with Texas Education Code and Regulations as established by the Texas Coordinating Board, and that the submission of false information is grounds for denial of admissions, withdrawal from class, or payment of any additional fees or penalties as required by law.
STUDENT'S NAME :                  
STUDENT'S SIGNATURE
DATE  :        
SPOUSE'S NAME :                  
SPOUSE'S SIGNATURE
DATE  :        
TO BE COMPLETED BY EVALUATOR
Total balance (D-A minus C-B)    
Fund availability    
Application acceptance / denial reason:    
Date :    
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