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Application Form

The applicant is filling out an application form for an English language program. They must pay the application fee today and submit required documents in a timely manner if they need an I-20 form. Contact and background information is requested, along with enrollment dates, visa status, emergency contacts, and preferred method of payment.

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anicolemoraes
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Download as PDF, TXT or read online on Scribd
25 views

Application Form

The applicant is filling out an application form for an English language program. They must pay the application fee today and submit required documents in a timely manner if they need an I-20 form. Contact and background information is requested, along with enrollment dates, visa status, emergency contacts, and preferred method of payment.

Uploaded by

anicolemoraes
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Application Form

Welcome to USA English Language Center! Please fill out the following information to begin your application process. You will
need to pay the application fee today to proceed, and you will need to turn in the required documents in a timely manner if you
require an I-20. Thank you for choosing USAELC and we look forward to helping you with your education goals!

Office Section - Student ID:


1. Applicant Information (Please print clearly)

Full Legal Name: ___ _____


First/Given Name Middle Name Last/Family Name

Male Female Birth Date: __________________________


Month Day Year

Country of Birth: ______________________ Country of Citizenship: ______________________

Email: @

Home Phone:______________________________ Cell Phone:________________________________

How do you prefer to be contacted: E-mail Phone Text Message *check your cell carrier for text rates

Current Visa Status: F (student) Other__________________

2. ENROLLMENT DATES: Program Start Date: Estimated Completion Date:


______________ ________________
Month Day Year Month Day Year
Total Course Enrollment: ___________________________
*ESL Classes are 12 weeks to complete.

3. Permanent Address (Home Country): 4. Local Address (inside the US):


Required for I-20

Address: ______________________________________ Street Address: ________________________________

_____________________________________ Apt. Number: _________________________________

_____________________________________
City: ________________________________________

City: _____________________________________ State: ____________________

Province: ______________ Postal Code: _________


Zip Code: __________________

Country: _________________________________

Revised: 08/2022
5. STUDENT VISA (F): 8. HOW DID YOU HEAR ABOUT USAELC?

Do you require an I-20 document from INTERNET – Google Search: ________________


USA English Language Center?
INTERNET - Other: _____________________
YES, I will need an I-20 document
SOCIAL MEDIA - Site: _____________________
NO, I do not need an I-20 document
FRIEND - Name of friend: __________________
Do you have any Dependants? If yes, please list their names:
OTHER: _______________________________
_________________________________________________

6. TRANSFER STUDENTS ONLY:

Name of your previous school:


9. DO YOU NEED HELP WITH HOUSING?
___________________________________________
USAELC does not have on-campus housing but can assist
Program end date at your previous school: you with accommodations. Assistance is provided for either
American Home-Stay or International Apartments.
___________________________________________

If you are on Student Visa (F), is your record with your YES, I need help with housing
previous school currently “Active Status”? NO, I do not need help with housing

10. PAYMENT:
YES, I am an Active Status

NO, my Status is: Terminated, Completed, Initial


I am allowing USAELC to collect the following today:

Admission Fees (For students applying inside the U.S.)


$75 Application Fee (non-refundable)
7. EMERGENCY CONTACT: $80 Book Fee (refundable upon cancellation)
Name of closest relative or friend: Admission Fees (For students applying outside the U.S.)
___________________________________________ $75 Application Fee (non-refundable)
$175 Administrative Fee (non-refundable)
Relationship to you: $125 Documents Preparation Fee (refundable upon cancellation)
___________________________________________ $80 Book Fee (refundable upon cancellation)

Phone: Optional Fees


______ I-20 Courier Fee (Fees paid on your behalf to 3rd party)
___________________________________________
What method of payment will you be using? (Circle one):
Email: Credit Card # ___________________________________
Credit Card Cash Bank Wire Check Other_____
___________________________________________
Expiration Date ___________ Security Code__________

STUDENT SIGNATURE REQUIRED:


By signing this application form I am confirming that I would like to apply to the USA English Language Center, and that the
information provided is accurate to the best of my knowledge.

Student Signature: Date:


________________________________ ______________________
2

Revised: 08/2022

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