Session: Month ___________________ Day _________ Year _____________
_______________________________________________________
Applicant Name: Family Name
First
Middle
Sex: o Male o Female Marital Status: o Single o Married
Date of Birth: Month __________________ Day __________ Year ______________
Do you have a high school diploma? o Yes o No
_______________________________________________________________________
Country of Citizenship
Country of
Birth
_______________________________________________________________________
Address in Your Country:
Number and Street
_______________________________________________________________________
City
Postal Code
_____________________________________________(______)___________________
Country
Phone
Number (include city code)
E-mail Address: ________________________________________________________
_______________________________________________________
Name of Friend or Relative in the U.S.A.
_______________________________________________________________________
Address of Friend or Relative in the U.S.A.: Number and
Street City
_____________________________________________(______)___________________
State
Zip Code
Phone Number
Do you want to apply for a F-1 visa? o Yes o No
(If yes, we will send the I-20 form.)
If you are already in the U.S.A., which visa do you have?
o F-1 o B-1 o B-2
o Other:
________________________________
If you are a transfer student, give the name of the institution that issued
your I-20:
_________________________________________________________________________
Have you studied English in the U.S.? o No o
Yes
If yes, where? ____________________________ How long? ______________________
After English studies you will:
Study for a degree: o B.A./B.S. o M.A./M.S. o PhD.
o Return Home o
Other
I certify that the information provided is accurate and complete.
Signature _________________________________________ Date ________________
