ב"ה

ד"סב

APPLICATION FORM

THE MECHINA

(English Print) Last Name _______________ First Name ________________

(Hebrew Print) Last Name ______________ First Name ________________

Passport # __________________ Nationality _________________

Current Address ______________________________________________

City State Zip Country__________________________________________

Phone No. ___________________ Mobile No.___________________

Email Address _________________________________________________

Gender: Male / Female Marital Status: S / M / D / W Number of Children : ___

Date of Birth ____/____/___ Country of Birth _________ DD MM YYYY

Status: Tourist / Oleh Chadash (New Immigrant)

Date of Aliyah _______ Were did you make Aliyah from (City Country) ___________

Would you like to apply for a Dorm-room? Yes / No

Made Aliyah with: Parents / Siblings / Husband / Wife / Alone

Father's Name: ______________ Country of Birth ____________

Mother's Name: ______________ Country of Birth ____________

Contact Details of Parents (if currently abroad): (To be contacted in case of emergency)

Full Address ____________________________________________

Home Phone No. __________________

Father's Mobile No. ______________ Mother's Mobile No. ______________

Email Address:_________________________________________________

Details of a Relative or a Close Friend in Israel: (To be contacted in case of emergency)

Name _________________________ Phone No. __________________

Full Address _______________________________ Relation: ________________

םיטנדוטסה ןקיד תכשל

םילועל הניכמה

Office of the Dean of Students

Pre- Academic Program

for new Immigrants

Tel: 03 531 8653 :לט  Fax: 03 738 4015 :סקפ  mechina.office@mail.biu.ac.il  http://www.biu.ac.il/Dean/mechina

Bar-Ilan University (RA), Ramat Gan 52900, Israel • www.biu.ac.il • רב תטיסרבינוא- ןג תמר ,)ר"ע( ןליא52900לארשי ,

Please

attach

3 I.D

pictures

Education:

Year of Graduation _____ SAT's (or Psychometric) Score:____

Name / Period of Study / Degree

High school

________________________________________________________

College / University

________________________________________________________

Jewish Institutions

_______________________________________________________

Army Service:

1. I Served _______ years, from _________ to ______________

2. I did not Serve

3. I Served abroad : Country ___________ No. of years ________

Which Health insurance do you have: __________________________?

Do you have any special health problems: _______________________?

_________________________________________________________

_________________________

Applicant's signature

Date

Please include the following with this application form:

• 3 Pictures

• High School Diploma + Grade Sheet

• $100 Registration Fees

• Ulpan Diploma (if available)

• Copy of ID Card or Passport (details page)

• Copy of Health Insurance Card (if available)

םיטנדוטסה ןקיד תכשל

םילועל הניכמה

Office of the Dean of Students

Pre- Academic Program

for new Immigrants

Tel: 03 531 8653 :לט  Fax: 03 738 4015 :סקפ  mechina.office@mail.biu.ac.il  http://www.biu.ac.il/Dean/mechina

Bar-Ilan University (RA), Ramat Gan 52900, Israel • www.biu.ac.il • ב תטיסרבינואר- ןג תמר ,)ר"ע( ןליא52900לארשי ,

1. I hereby agree to pay the full tuition for this program ____________ , including all

students' fees and all other required fees as detailed from the instructions detailed

on the University's website (www.biu.ac.il/Dean), and all decisions made by the

University's authorities, which may vary from time to time.

2. I am well aware that any delay in payment of said fees will result in overdue

fines in linkage rates posted on the University's website. I am also aware that

regardless of any other legal remedies in such matters, the University is entitled

to take different actions (such as discontinuing my education or services

rendered, etc.), all included in the relevant abovementioned instructions.

3. I am aware that in all matters regarding debts, unpaid fees and standing debts, the

University's records will be considered evidence in my case.

4. I hereby agree to resolve all tuition payment issues within 90 days from the first

date of studies at the latest.

5. I am fully aware that should I unregister from the program before the first

semester has began, I will be charged with the cost of a Summer Ulpan, and at

any case, with no less than 25% of the full program's tuition fees.

I am also aware that should I unregister from the program after the first semester

has began but before it has ended, I will be charged with 50% of the full

program's tuition fees.

6. I confirm that I was informed of the University's policies and requirements

regarding studies discontinuation notice, and the different rates to be charged

pending date of discontinuation notice. I am also aware that in addition to the

aforementioned requirements, the studies discontinuation notice will go into

effect if and only if and when my notice is received in writing by registered mail

or by personal delivery with a signed approval of acceptance by the Mechina

office, and that any other form of discontinuation notice is null and void.

I hereby agree to act according to the conditions detailed above and pay the

remaining sum of my debt to the University accordingly.

_________________________

Applicant's signature

Date

Please send this application form via email: [email protected]

םיטנדוטסה ןקיד תכשל

םילועל הניכמה

Office of the Dean of Students

Pre- Academic Program

for new Immigrants

Tel: 03 531 8653 :לט  Fax: 03 738 4015 :סקפ  mechina.office@mail.biu.ac.il  http://www.biu.ac.il/Dean/mechina

Bar-Ilan University (RA), Ramat Gan 52900, Israel • www.biu.ac.il • רב תטיסרבינוא- ןג תמר ,)ר"ע( ןליא52900לארשי ,