AHP Insurance New Student Form

Board of Governors Regulation 6.009 Admission of International Students to State University System Institutions, Section 2.
No international student in F or J non-immigrant status shall be permitted to register, or to continue enrollment, at a university without demonstrating that the student, and in the case of J visa holders, that their accompanying spouse and dependents have adequate medical insurance coverage for illness or accidental injury.

Name Name First Last
Gender:
Date of Birth Date of Birth / MM / DD YYYY
Panther ID #
Today's Date Today's Date / MM / DD YYYY
Email
Student Category:
Address: Current US Address. Address: Current US Address.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Signature: I clearly understand that I must satisfying the Florida Board of Governor's Requirements for international students’ insurance.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.