B1/b2 Visa Holder Intensive English Program Application Form
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2B1/B2 VISA HOLDER INTENSIVE ENGLISH PROGRAM APPLICATION
For Office Use Only: Date Received (MM/DD/YYYY): ____________
CSC Consultant (initials): _________
Applicant Information: Please print your name as it appears on your passport in all capital letters. In
addition, provide a copy of your passport and/or visa.
Family/Last Name: ____________________________
First Name: __________________________________
Date of Birth (MM/DD/YYYY): ___________________
Gender: □ Male
□ Female
Country of Birth: ______________________________
City of Birth: _________________________________
Country of Citizenship: _________________________
Email Address: _______________________________
Program Dates
(Program dates must begin with the Placement Test and end with the last day of class):
Start Date: (MM/DD/YYYY) _____________________
End Date: (MM/DD/YYYY) ______________________
Check Highest Education Level completed
: □ Less than High School
□ High School Graduate or Equivalent
□ Technical Degree
□ Some College
□ 2-Yr Degree
□ 4-Yr Degree □ Master Degree □ Doctorate Degree
U.S. Local Address:
Street Address, Apt #: ___________________________________________________________________________
City, State, Zip Code: ____________________________________________________________________________
Telephone: ____________________________________________________________________________________
PLEASE READ AND SIGN:
By signing below, I certify that all information in this application is complete and accurate.
I have read and understand the cancellation policy. Students under 18 must have a parent or legal guardian
signature.
Student Signature: _______________________________________
Date: _____________________________
Parent Name: ___________________________________________
Parent Signature: ________________________________________
Date: _____________________________
PAYMENT INFORMATION: □
Visa
□ MasterCard □ Discover
□American Express
Name as it appears on the card: ___________________________________________________________________
Card Number: __________________________________ Expiration Date : ____________________ (MM/DD/YYYY)
CCV #: _______________ (3 or 4 numbers)
Amount to Charge: $_________________
I authorize use of my card to pay for the application fee and program deposit for the amount stated above.
[Type text]
Signature: _______________________________________
Date: ________________________
Last Updated 02/19/2014
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