iep application by 9393ely


									                                      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
        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
        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:

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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