STUDENT:

If ACCEPTING YOUR PLACEMENT, complete missing information in parts A, B, and E on each copy of this form. Read Part D. Read the
Conditions of Placement. Sign and date each of the three copies of this form and the Conditions. Keep one copy of this form and one copy of
the Conditions for yourself.

If DECLINING YOUR PLACEMENT, Check Part C; indicate the reason for declining; and sign and date each copy of this form. Keep one
copy for yourself and return the other two copies to your HOME campus NSE Coordinator.
HOME COORDINATOR:

For March conference placement, mail one copy of the form and Conditions to the host coordinator postmarked no later than April 1 or
placement may be rescinded.

For post-conference placement, one copy of the form and Conditions must be mailed to the host coordinator immediately following placement.
Placement is not confirmed until one signed copy of each of this form and the Conditions are received by the HOST NSE coordinator. A new
PPAF must be completed if the time period of the original exchange is modified or extended. Changes may be made to the original PPAF as
long as each change is initialed and dated by the student as well as the host and home coordinators; and a copy is on file on both the home and
host campuses.
PART A: Participant Information
NAME:
GENDER:
BIRTHDATE:______________
HOME CAMPUS:
GPA:_____________________
MAJOR:
NSE I.D.:__________________
I will be at my current address until: ___/___/____
CURRENT ADDRESS:
CELL PHONE:_____________
PERMANENT ADDRESS:
HOME PHONE:____________
SUMMER ADDRESS:
EMERGENCY:_____________
EMAIL:
ALTERNATE EMAIL:_______________________________________
PART B: Accepting the Placement
- I ACCEPT my placement AT:
For exchange period:
ON: Plan B
Academic Year 20____
I plan to: _____live on campus _____live off-campus
My citizenship is:
_______
PART C: Declining the Placement
- I DECLINE my placement.
Reason: _______________________________________________
PART D: Special Conditions or Circumstances
Questions below are designed as a self-assessment guide. It is not necessary to answer on this form, but if your answer to any of the
questions in this section is YES, you should immediately identify yourself and your needs to your host campus coordinator.
Notification at least two to three months prior to arrival on campus is necessary in order for your host institution to address
your needs. You will be asked to submit documentation which is written, current, and prepared by a qualified professional in the
manner and time period required by your host campus. You will also be asked to identify the kind of arrangements that are currently
being made for you at your home campus. Consult home and host disability service coordinators for additional information. Failure to
provide documentation, in the manner and time required by the host campus, may mean that needed services cannot be provided.




Do you have any medical condition which might require immediate medical attention during your exchange?
Do you have any conditions which may affect your emotional or mental well-being during your exchange?
Do you have any physical conditions for which you will need accessible on-campus housing and/or classroom
accommodation?
Do you have any documented disability which may require academic accommodations (e.g., note takers, taped texts) during
your exchange?
PART E: Emergency Contact
Identify a person or persons (parents, guardian, spouse, etc.) who should be informed in the event of any
situation determined to be an emergency by the host NSE Coordinator or designee.
NAME: _______________________________________RELATIONSHIP: ____________________________
ADDRESS: ____________________________________CITY, STATE/PROVINCE AND CODE:
_________________________________________________________________________________________
HOME PHONE: _____ - _____ - _____CELL: _____ - _____ - _____ EMAIL: ________________________
SIGNATURE
I affirm that the information on this form is complete, accurate, and true to the best of my knowledge. I have
read this form, including the Conditions of Placement. I understand its contents, agree with its conditions, and
acknowledge that I am signing it freely, voluntarily, and under no compulsion.
Student (please print name): __________________________________________________________________
Student (signature):
___________________________________________ Date: ___________________
Consider the length of your exchange (part of the academic year or all of the academic year), the number of times you are
likely to travel to and from your home to your host campus, and the cultural and travel/sight-seeing opportunities you
would like to take advantage of while on exchange. Also note the following:
 Tuition and fees frequently increase from 5-15 percent per year.
 Room and meals frequently increase in excess of 5 percent each year.
 Financial aid while on exchange may vary from that which you currently receive.
Estimated Costs:
Per Term
Academic Year
Plan B: Home Tuition Fees
Host Room and Meals*
Books/Supplies*
Insurance*
Transportation on the
Host Campus*
Personal Expenses*
Other
Travel to/from Host
Miscellaneous
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
=========
========+
$________
$________
* Figures are available from Campus Budgets at
www.nse.org, Students, Resources.



Calculate Plan B tuition & fees (SCSU)
Calculate all other fees on the calendar
of your host campus.
For an Academic Year exchange, tuition
and fees at semester schools are paid
twice a year. Tuition and fees at quarter
schools are paid three times a year.
Total Estimated Costs
In addition to costs estimated above, other additional expenses may include fees that are a condition of your enrollment (e.g., general service,
laboratory, art and photography supplies, field experience, student teaching, internship, technology fees, computer fees, etc.) and other fees (e.g.,
application, orientation, field trips, NSE program fees, health services, parking, special events, student activities, athletics, etc.) See campus catalogs
and NSE Campus Profiles for additional information.
Student Resources:
Per Term
Personal Savings
Family Support
Federal Grants/Loans
Pell Grant
Work Study
Perkins
SEOG
FFEL
Parent Plus Loan
State Financial Aid
Scholarships
Work on exchange
Other: _______________
_______________
$________
$________
$________
$________
$____0___ *Work Study
$________ not applicable on Plan B
$________
$________
$________
$________
$________
$________
$________
$________
U.S. Federal Financial Aid
 For Plan B: apply for, and disbursed from the
home campus.
Other Aid
Not all aid is applicable to exchange programs and some
may be dependent upon Plan B. Check with your financial
aid officer and/or scholarship source.
Annual Total
 Multiply the Total Estimated Resources by 2 if
you plan to exchange for a semester calendar
academic year.
 Multiply the Total Estimated Resources by 3 if
you plan to exchange for a quarter calendar
academic year.
=========
$________
Total Estimated Student Resources
This form must be completed, signed, and returned
to the OIE Coordinator prior to exchange.
Student’s Name _____________________________________________ Student I.D. _____________________________
Major______________________________________________ Expected Date of Graduation ______________________
Period of Exchange _________________________________________________________________________________
Status During Exchange ____ sophomore ____ junior ____ senior ____ other __________________________________
Host Institution _____________________________________________________________________________________
Calendar at Host Institution ____ semester* ____quarter*
Note from the OIE Coordinator:
*Courses transferring from a quarter calendar to a semester calendar generally earn one-third less value than semester
credit hours. Courses transferring from a semester calendar to a quarter calendar will generally earn one third more
value than quarter credit hours. Fractions of hours may be rounded up or rounded down as deemed appropriate by
institutional policy. A full-year exchange is strongly encouraged when moving between the two calendars.
Directions for the Student:
On the reverse side of this page, list the department, number, title, and credit hours for each course you might take at the
host institution as described in the host college catalog. You should select at least twice as many courses as you plan to
take on exchange and list courses for the entire period of your exchange, not just for your first term. For each course
selected, attach a copy of the course description. Your academic advisor and major department Chair will indicate how
each course will be accepted (e.g., major requirement, major elective, elective). Secure the signatures of your advisor and
department Chair, sign and date the form, and return it to the Office of International Education at least two months prior to
your exchange.
NOTE: Access to courses at your host campus is based on offerings and availability and cannot be guaranteed. You must
meet all pre-requisites or co-requisites as required by the host campus.
Required Signatures:
Academic Advisor ___________________ Signature__________________________________ Date ______________
Title and Department ________________________________________________________________________________
Telephone __________________________________________Email _________________________________________
Dept. Chair: Printed Name ___________________Signature ___________________________Date ________________
Student ______________________________________________________________________Date ________________
OIE Director ___________________________________________________________________Date _______________
A final copy of this signed agreement will be sent to the student and to the advisor. The original will be kept in the OIE.
Student Name: ___________________________________________________ Student ID:____________________________________
COURSES FROM HOST CAMPUS CATALOG
Host Dept.
Course
Number
Example:
HIS 241
Major
Requirement
Title
History of the American West: Part I
Major
Elective
Elective
X
Other
Host
Credit
Hours
Home
Credit
Hours
3.0
3.0
Comments: _________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
If additional space is required, make a copy of this side prior to completion