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    Academic INFORMATION

General Information

Personal Details

Permanent Address Details

Mailing Address Details


Family Information

Parent/Guardian #1

Address Details

Contact Info

Parent/Guardian #2

Address Details

Contact Info

Sibling # 1 (optional)

Emergency Contact Information

Academic Information

High School Information

To be considered for admission, you must submit a state-certified High School diploma (and transcript) or equivalent. Send final official records after graduation

Standardized Test Information such as TOEFL, IELTS, SAT, ACT, CLEP, etc., if applicable (optional)

You need to request the testing center to send the result to Sampoerna University

Test # 1 (optional)


The United States’ Family Educational Rights and Privacy Act of 1974 (“FERPA“) grants students and eligible parents certain rights and privacies regarding education records of students applying to or attending postsecondary institutions. By submitting this form, the student may consent to release his/her educational records and/or other information to a third-party for a defined purpose. A new form must be submitted for each request.

To applicants :

By checking this box, you authorize Sampoerna University to share application data and any relevant educational records with Broward College, our U.S. Partner institution, for the purpose of dual enrollment and credit.

You hereby release Sampoerna University, its Trustees, Officers, and Employees, including the Admissions Officers and College Registrar, Agents or Assigns, from any and all liability for release of the above named records/information. This authorization is valid until canceled. You may cancel this release at any time by submitting another FERPA form to the Sampoerna University or Broward College Office of the Registrar.

You also certify that all information in this application to the best of your knowledge is factually true and that you are the person submitting this application. You understand that a false statement may disqualify you from the admissions process