Appendix B: Study Abroad Form Requiring a Guardian's Consent for Female University Students

[Translated by Human Rights Watch from the Arabic original]

The Kingdom of Saudi Arabia

Ministry of Higher Education

Agency of Cultural Relations

General Directorate of Research

Permission Request Form to Study Abroad at Personal Expense

Personal Information:

1. Name (at least to the fourth degree) in Arabic: ………………………………………………

Name in English (as appears in passport): …………………………………………………………

2. Date of Birth: ………../……../…………………        Place of Birth:

3. Marital Status                                             Single ˜                                              Married ˜           

4. Number of Civil Registry: Issued on: ……./……../………Issued in: ……. /……../………

5. Passport: Issued on: ………../……../…………………             Place of Issue:

6. Permanent Address:                PO Box:                                Zip Code:                            City:              

Phone Number:                               Fax Number:                      Email Address:

Educational History :

1. High School Degree ………………………………………………………………………

Percentage                                        Date [of graduation]                                      Issued by: 

2. Last degree issued: Issued by:                                           Date: ………../……../…………………

3. Did you study at a university in Saudi Arabia or elsewhere?                               

No ˜                       Yes ˜     (Please provide the following information)

Name of University:                                                       Academic Year:

University number/ code:                                          Number of hours completed:

4. Are you a government employee?  No ˜                          Yes ˜     (Mention the division)

5. Desired academic level:

˜ Diploma          ˜ Baccalaureate             ˜ Masters           ˜ Fellowship      ˜ Doctorate

6. Specialty:                                                                      7. Enrollment:    ˜ Full-time        ˜ Part-time

8. Name of university:                City:             Governorate/ District:                State:

Give the names of three references that you know well and their addresses:

Full Name	Address	City	Phone Number(s)
1.
2.
3.

I hereby certify that the above provided information is accurate. 

The applicant must read carefully the following consent forms and sign the relevant ones:

I, student [Name] -------------------------------------------------- hereby certify that:

I am NOT an employee and do NOT work in any government division.

Signature:

I commit to not leave my educational institution before paying back all my financial obligations.  I also commit to pay back any fees that would cause financial claims after my departure.   I commit to provide the cultural attaché office at least an annual report about the progression of my education.

Signature:

Certification applicable to students of Medicine

I acknowledge that I will take an exam upon my return with the degree from the Saudi Committee of Medical Specialties, the results of which will determine whether I will be authorized to practice. 

I commit to consult the bylaws and the guidelines of the practice of Medicine in Saudi Arabia and abide by them.

Signature:

I, guardian of the [female] student ………………………………………………  commit to accompanying her during her entire schooling.

Name:                                                                                                  Relationship:

Signature: