Boston University International Student Data Form

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This form must be completed by all international students applying for admission. Please answer all of the questions completely and return
the form with the requested financial documentation and copies of U.S. immigration documents (if applicable) to the Admissions Office
reviewing your academic application. Once you have been admitted to a program of study (and, in some cases, once you have formally
accepted the offer of admission), the Admissions Office will send this form, the supporting documents, and a file to the Boston
University International Students & Scholars Office (ISSO). Once your file has been reviewed and determined to be complete, the ISSO will
forward an official immigration document to you with instructions on how to apply for the student visa at the nearest U.S. Embassy or
Consulate. If you are currently in the U.S., the ISSO will forward specific immigration instructions to you to facilitate your enrollment.

General Information (Please enter all names exactly as they appear on your passport)

Name Maliogha Albert Josua Putera Female

family/last first/given middle Male

Date of birth 06/29/1991 Place of birth Poso Republic of Indonesia

month day year city country
Republic of Indonesia Republic of Indonesia
Country of citizenship Country of legal permanent residence
Permanent address in home country:
Street Jl. Mawar No. 14 RT/RW 003/006 Kamalaputi City Waingapu State/Province East Nusa Tenggara

Country Republic of Indonesia Postal code 87111

E-mail [email protected]

If you wish correspondence to be sent to you at an address other than the one above, please write it here:
Street City State/Province
Country Postal code
This address can be used for mail from to
month day year month day year

Financial Declaration
Boston University is required by U.S. government regulations to check the availability of adequate funding for your tuition, fees, and living expenses for the duration of
your studies at Boston University to issue the immigration documents necessary to obtain a student visa. All financial documents submitted for evaluation will become the
property of Boston University and will not be returned to the applicant. It is recommended that you request multiple copies of the documentation listed below to submit
at the point of visa application and to retain for your records. Please refer to the Estimate of Expenses for the breakdown of fees and for the minimum required per year.
All declarations of financial support must:
1. Reflect the minimum amount of support in U.S. dollars
2. Specify funding for study at Boston University (not another college or university)
3. Include a date and be no more than one year old from the intended date of enrollment
4. Indicate the period of time for which the support will be provided
5. Be written in English
6. Reflect funds that are readily available for tuition payment (i.e., checking or savings accounts).
Certain investment accounts such as stocks, salary documents, property holding, etc. do not reflect available funds and will not be accepted.
Please check the box below which describes the type of funding you will be receiving, and attach the appropriate official documentation as outlined below. Please note that
additional funding must be provided for any accompanying dependent for which a document will need to be issued. Dependents are defined as spouse or unmarried
children under the age of 21.
If you will be funded by a family member, please submit:
1. A letter of sponsorship which indicates that your sponsor is willing and able to support you financially for your academic fees and living expenses
throughout the duration of your studies at Boston University. The letter must also indicate the sponsor’s relation to you (i.e.: mother, father, etc.)
2. An official bank statement or letter or credit reference from a bank stating the availability of the minimum estimated expenses as indicated on the
Estimate of Expenses.

If you will be funded by your government, an organization, a company, etc., the sponsor must submit a letter of sponsorship on official letterhead which states:
1. That your funding is valid specifically for Boston University.
2. Exactly which expenses will be covered (i.e., academic fees, living expenses, health insurance, financial support for family members, travel, etc.)
3. The length of the financial support.

If you will be funded by a bank loan, you must submit an official letter of certification from the lending institution indicating the specific amount for which you
have been guaranteed.

If you have received a financial award from Boston University (i.e., Fellowship, Assistantship, Scholarship, etc.) you may not need to provide additional financial
documents if the award will meet or exceed the Estimate of Expenses.

If you will be funded in a manner not listed above (for example, if you will fund yourself), you must submit official documentation (a bank statement or a credit
reference from a bank) indicating the specific amount.
Educational Information
List all schools, colleges, or other institutions including English language program you have attended or are attending in your country and elsewhere, including the US:
Dates
Name of Institution Location Degree (if applicable)
(from - to)
Satya Wacana Language Training Center Salatiga, Central Java- Indonesia 01/04/2017 to 22/04/2017
TEST English School Pare, East Java- Indonesia 11/01/2016 to 04/06/2016
Satya Wacana Christian University Salatiga, Central Java- Indonesia Bachelor of Science in Theology 01/09/2009 to 10/02/2015
to

Immigration and Visa Information

All applicants must submit:
a dark and legible copy of the personal data page of your passport including the page that indicates the passport expiration date

In addition, if you are currently in the U.S. or have been in the U.S. during the past six months, please check the appropriate box below and submit dark,
legible copies of the requested documents:
F-1 student status: copies of the first and third page of all of your Form(s) I-20, copy of the most recent F-1 visa stamp in your passport (if applicable),
copy of the most recent U.S. Entry Stamp in your passport and paper I-94 document (if applicable), and front and reverse side of any Employment
Authorization Card(s) (if applicable)
J-1 Exchange Visitor status in any category: copies of all of your Form(s) DS-2019, copy of the most recent J-1 visa stamp in your passport (if
applicable), and copy of the most recent U.S. Entry Stamp in your passport and paper I-94 document (if applicable)

F-2, J-2, H-4 or any other dependent immigration status: copy of the most recent visa stamp in your passport (if applicable), copy of the most recent
U.S. Entry Stamp in your passport and paper I-94 document (if applicable), and copies of all immigration documents from your spouse or parent on
which you are dependent for your immigration status

Any other immigration status: Copy of the most recent U.S. Entry Stamp in your passport and paper I-94 document (if applicable), copy of the most
recent visa stamp in your passport (if applicable), copies of all of your Form(s) I-797 and/or any other relevant immigration documents

If you are not currently in the U.S., to which U.S. Embassy or Consulate do you intend to apply for your visa stamp?
Jakarta Republic of Indonesia
__________________________________________________(Please include the city and the country)
City Country

Family Information
Your spouse and your children (under the age of 21) are eligible to apply for dependent visas to accompany you to the U.S. or to join you at a later time.
Please complete the information below about each dependent (whether or not your dependent(s) will be included in your visa/status application).
1. Do you have any dependents (as defined above)? No Yes. How many? 1
2. Are your dependents
Are your dependentscurrently
currentlyininthe
the U.S.?
U.S.? No Yes - please also provide copies of their
immigration documents.
3. Are you requesting for BU to issue a dependent immigration No Yes - please provide a copy of each of your
document for your dependent(s) to assist them with applying dependent(s)' passport.
for a dependent visa?
Dependent 1 Dependent 2 Dependent 3 Dependent 4
Family/Last Name Sihombing
First/Given Name(s) Ika
Middle Name(s) Sri Astuti
Date of Birth (month/day/year) 06/09/1990
City of Birth Bandung
Country of Birth Republic of Indonesia
Country of Citizenship Republic of Indonesia
Country of Legal Permanent Residence Republic of Indonesia
Relationship* Wife
Current immigration status, if in U.S.
* Please indicate “Wife,” “Husband,” “Son,” or “Daughter.” If you have more than four dependents, list them on an additional sheet.

Last Position Held in Home Country

Please give the title and a brief description of the most recent (or current) position held in your country of citizenship or country of last legal permanent residence. If the
last position was that of student, please write “Undergraduate student” or “Graduate student.”
Undergraduate Student
Please choose the category that best describes the employer of the above position:
Government Academic Community Private Sector The Arts or Sports Labor Union or Organization Communications/Media Military

I attest that the information I have provided above is accurate, and I understand that it will be released to the U.S. Department of Homeland
Security to create official immigration records for me and my dependent family members. I understand that I am responsible for submitting
adequate financial documentation demonstrating my ability to pay for my tuition and living expenses. Failure to report accurate information
could jeopardize my eligibility for a U.S. visa or my ability to enter the U.S. and enroll in my academic program.

Signed Dated
Boston University prohibits discrimination against any individual on the basis of race, color, religion, sex, age, national origin, physical or mental disability, sexual orientation, or marital, parental, or veteran status. This policy
extends to all rights, privileges, programs, and activities, including admissions, financial assistance, employment, housing, athletics, and educational programs. Boston University recognizes that nondiscrimination does not ensure
that equal opportunity is a reality. Because of this, the University will continue to implement affirmative action initiatives which promote equal opportunity for all students, applicants, and employees. Inquiries regarding the
application of this policy should be addressed to the Director of Equal Opportunity, 25 Buick Street, Boston, Massachusetts 02215.