INTENSIVE ENGLISH PROGRAM APPLICATION

INTENSIVE ENGLISH PROGRAM APPLICATION

SECTION 1: General Information

Full Name:

First

Sex: Female Date of Birth: Male Month/Day/Year

Middle

Last (family Name)

What is your country of Birth? What is your country of Citizenship?

Are you a United States Citizen: Yes No Do you plan to apply for an F-1 Student visa? Yes Do you presently have a United States visa? Yes

Are you a Permanent Resident: Yes

No Social Security number:

No

If yes, What type:

Local U.S address:

(if available)

Street Number/Street Name

City

State

Phone Number:

(Where you can be reached)

E-mail:

No Zip Code

How did you hear about us? Former student Friend A family member

Chattahoochee Tech International Services Department

Agency Chattahoochee Tech website Other

According to you, what is your English level NOW? None Beginner Intermediate

What is your main reason for studying English in the United States?

To prepare for undergraduate study

To get a better job

To prepare for graduate study

For social reasons

Other

Advanced

SECTION 2: Term / Enrollment Status

Which term do you plan to start?

Spring 1, 2022

01/18/22 to 03/10/22

Fall 1, 2022

08/15/22 to 10/06/22

Spring 2, 2022

03/28/22 to 05/19/22

Summer, 2022

06/06/22 to 07/28/22

Fall 2, 2022

Summer, 2020

10/17/22 to 12/08/22

06/10/19 to 08/02/19

(F-1 visa student MUST enroll Full-Time)

Full-Time $1,580

If Part time, which course would you like to take?

Intergrated Skills

Writing

Reading

Grammar

Part-Time $340/per course Speaking/ Listening

** Please note: Price includes tuition and one meal at the end of each session. Prices are subject to change **

FOR BURSAR'S OFFICE USE ONLY: STUDENT ID:

VISA TYPE:

DATE OF PAYMENT RECEIVED:

INNITIALS:

SECTION 3: Visa Information

Are you curently in the United States with an I-20 and plan to transfer? Yes No If yes, What school issued your I-20:

Permanent Address:

(in your country)

Permanent Phone Number:

(in your country)

Do you want to include your spouse and/or children on your SEVIS Form I-20? Yes No

Name:

Relationship:

Date of Birth:

Country of citizenship:

Country of Birth:

Name: Relationship: Country of citizenship:

Date of Birth: Country of Birth:

All students requesting an I-20 must demonstrate evidence of financial support for their stay in the U.S.

F-1 visa students are required to enroll for a minimum of 20 clock hours each term.

Financial declaration, per 8 week term (160 hours of instruction):

**Tuition: $1,580 USD Estimated cost of living: $1,668 USD

Books: $250 USD

Total Financial Obligation: $3,498 USD **Please note: the cost of tuition is subject to change**

Please indicate how many terms you wish to enroll: 1 Term: $3,498 2 Terms: $6,996 3 Terms: $10,494 4 Terms: $13,992 5 Terms: $17,490

Add $4,500 per dependent ; Please attach an original bank statement with the sponsor's name indicating funds available for the number of terms selected.

SECTION 4: Signature / Submission Instructions My signature on this application is my acknowledgment of an agreement with the statements that follow:

I understand that the application for admission to the Intensive English Program does not constitute or guarantee admission to any Chattahoochee Tech (CTC) credit programs. I understand that I do not choose my level. My level will be based on my placement test score. I understand that there is no refund after classes have started. I understand that pursuant to o.C.G.A 16-10-20, it is a felony to make a false statement on any state document. In addition, making a false statement may result in dismissal from the college. I give permission for my likeness, voice, or comments to be used in any promotional item on behalf of CTC. I give permission for CTC to release information to potential employers as part of the job placement service provided by the college. I understand that CTC is not liable for any emergency medical attention provided nor for charges incurred from such. I give CTC permission to contact me at the telephone numbers I have provided via any means, including text message or voice.

Signature

A Unit of the Technical College System of Georgia. Equal Opportunity Institution.

Date

Revised: 07/12/2021

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