Intensive English Program Center Application Form I am applying for the following session: _____ Fall I 2012 _____ Fall II 2012 _____ Spring I 2013 _____Spring II 2013 _____ Summer 2013 Applicant Information: Family Name: ______________________ First Name: ___________________ Middle Name: _____________ Sex: __ Male __ Female Date of Birth: _____ Month / ______ Day / _____ Year Country of Birth: ________________________________ Passport Issued by: ___________________________ Native Language(s):_____________________________________________________________________________ Applicant Contact Information Mailing Address (include PO Box, Apt. #, Building #). If you are applying for an F-1 visa, please use your foreign mailing address. Street Address:______________________________________________________________________________ City: _______________________ State: ________________________ Country: ____________________ Postal Code: __________________ Home Phone: __________________________________________________________________ Cell Phone: ___________________________________________________________________ Email: _______________________________________________________________________ Emergency Contact Information (Person to notify in case of an emergency) Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ Home Phone: __________________________________________________________________________________ Work Phone: _________________________________________________________________________________ Email: _______________________________________________________________________________________ (continued on next page) Immigration Status Choose one: _____ I am in the United States right now. _____ I am outside the United States right now. Choose one: _____ I will apply for an F-1 student visa. _____ I will transfer with an F-1 student visa. ____ I will change my visa status. My current visa status is __________. _____ I do not require help with a student visa. I will study with a ________ visa. _____ I am a permanent resident/green card holder. _____ I am a U.S. citizen. How did you hear about KSU’s Intensive English Program? ___ IEP Website ___ Friend or relative ___ Former or current IEP student ___ KSU faculty/staff member ____ Other: _____________________ What are your plans after you attend Kennesaw State University’s IEP? For example, do you plan to pursue studies in an American university? ____________________________________________________________________________________ Do you plan to study full-time or part-time? _____ Full-time _____ Part-time F1 visa students must study full-time. All others may study part-time or full-time. If part-time, how many classes will you be taking? ______ If part-time, please circle the classes you are interested in: Reading Writing Grammar Conversation & Pronunciation Vocabulary & Idioms Listening & Speaking TOEFL Preparation F1 visa students go to next page. All other students go to final page. (continued on next page) For students who have or need an F-1 international student visa: Are you transferring to the IEP from another school in the United States? ___ Yes ___ No If yes, which school are you transferring from? ______________________________________________________ Address of school: __________________________________________________________________________ Contact telephone number of school: ____________________________________________________________ Fax number of school:________________________________________________________________________ Accompanying Family Information (for F1 visa applicants only) Complete the following if you have a spouse or child who will be accompanying you to the U.S. Please use back of form to note additional dependents. Supply the following information if you want to include your spouse or children on your I-20 form. Family Name: ______________________ First Name: ___________________ Middle Name: _____________ Relationship: __________________________________________________________________ Date of Birth: _____ Month / ______ Day / _____ Year Country of Birth: _______________________________________________________________ Important information for students who have or need an F-1 visa: You will need an I-20 from the IEP. This is the document that allows you to get an F-1 from the American Embassy or American Consulate. To receive an I-20, you must have proof of holding $4,000.00 USD in a bank for estimated educational and living expenses in the U.S. For each additional family member you should have an additional $2000 in the bank for each eight weeks. Please complete the next page and send the following documents with your application. 1) a completed financial statement showing a minimum of $4,000 (next page) 2) original financial statement showing a minimum of $4,000 3) a completed and signed affidavit of support (next page) 4) a completed immunization record 5) an application fee payable to Kennesaw State University (I understand that the application fee is non-refundable and nontransferable. Important information regarding mandatory health insurance for F-1 visa students: All F-1 visa holders studying in the United States must have health insurance. Kennesaw State University requires its F-1 visa students to have health insurance with a certain amount of insurance coverage before the beginning of the semester. Additional information regarding health insurance will be sent after applicant obtains an I-20. Students planning to come on an F-1 visa, please sign the following: I, ______________________________, understand that all F-1 visa holders must have health insurance while in the United States. If accepted into the program, I will obtain the required health insurance. ____________________________ ________________ Student’s Signature Month/Day/Year (continued on next page) For students who have or need and F-1 international student visa Financial Statement (must be completed for an I-20) Total must be equal or be greater than US $4,000 .00 $ __________________ Where will you receive your support? Check one. __________ My own funds _________ My parents _________ Other sponsor (specify) ___________________________________________________ _________ Sponsoring agency (specify) _______________________________________________ Obtain two original letters for required financial documents. Send one original letter to the IEP with your application. The other original letter is given to the U.S. embassy or consulate when you apply for the F-1 visa. Bank letters should be written on official bank letterhead, in English (or have a certified translation attached), stamped and signed by a bank official. The letter should state name of the account holder, the date the account was opened, the currency type, and specifically state the amount that is currently in the account. All documents must be originals. Affidavit of Support for ____________________________ I, __________________________ (name of sponsor), do swear that I will make available to _________________ (name of applicant) a total of ______________ for each 8 weeks of study at Kennesaw State University’s Intensive English Program. This money is in addition to any passage money needed for return to the country of origin. I understand that Kennesaw State University will not be able to assist the student financially. I, the undersigned, realize that I am fully responsible, and will be held accountable by the University for maintaining the terms of this statement. I am not a nonimmigrant student and I do not hold any other temporary status in the United States. My relationship with the applicant is _______________________. Signature of sponsor ___________________________________ Date _________________________________________ Sponsor’s address ___________________________________________________________________________ __________________________________________________________________________________________ (continued on next page) All students must read and sign the following 1) I certify that all information on the application is true and accurate. 2) I understand that admission to KSU’s IEP is not the same as admission to a degree program at Kennesaw State University. I must submit a separate application to a degree program at Kennesaw State University. 3) (For F-1 visa students only) I certify that the stated funds on the financial statement are available for my educational expenses in the IEP at Kennesaw State University. 4) I understand that the United States Immigration and Naturalization Service will be notified immediately if I am dismissed from the Intensive English Program or if I fail to attend. 5) I understand I will take an English placement exam in order to determine the appropriate level of English language courses. ______________________________ _____________________________ Student’s signature Month/Day/Year Mail the completed form to: Intensive English Program Center Department of English Kennesaw State University 1000 Chastain Road, #2701 Kennesaw, GA 30144-5591 For questions: 678-797-2214 Or email@example.com Check list for applying to KSU’s IEP. Have you sent the following? _____ I have completed all parts of the application. _____ I have included the appropriate application fee (international money order or check) to the Intensive English Program. _____ I have included documentation (original bank letter or statement) indicating a guarantee of financial support. _____ I have included a copy of my passport (for visa students) or other photo ID. _____ I have included a completed immunization record (for F-1 visa students).
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