Ⅰ. PERSONAL INFORMATION
1. NAME:
Last Name
First
Middle
2. PERMANENT ADDRESS: (permanent address in home country is required. No P.O. Boxes, must be actual street address)
Street:
City:
Country:
Zip Code:
(No P.O. Boxes, must be actual street address)
3. COUNTRY OF BIRTH:
4. COUNTRY OF CITIZENSHIP:
5. PHONE:
FAX:
EMAIL:
6. SEX:
( ) Female
( ) Male
7. DATE OF BIRTH:
(we cannot issue an I-20 without an email address)
________/_________/___________
month
day
year
8. SOCIAL SECURITY NUMBER: _________-__________-______________ (if you have one)
9. DEPENDENT INFORMATION: (Husband, wife, children)
Name
City of Birth
Country of Birth
Gender
Date of Birth
Relationship
Ⅱ. PROGRAM AND SESSION Please check (x) the program and the session you want to attend. Intensive
Intensive English Program - IEP
□ Fall (15 weeks)
□ Spring (15 weeks)
□ Summer (8 weeks)
□ Summer (4 weeks)
□ Intensive English Plus - PLUS (4 weeks in summer)
Ⅲ. HOUSING Please check (x) one.
Are you interested in campus housing? (If available)
□Yes
□No
No Are you interested in homestay?
□Yes
□No
Will you have your own transportation?
□Yes
□No
Ⅳ.LANGUAGE SKILLS/STUDY
1. What is your native language?
2. Previous study of English: List countries, institutions, number of years.
Note: Minimum 1 year of English training is required for admission to UCAELI.
If English proficiency is below the minimum required, additional fees may be assessed for private tutoring.
Name of Institution
Country
Number of Years
3. How would you rate your overall English competency?
□ Beginner
□ Elementary
□ Intermediate
□ High Intermediate
□ Advanced □ Bilingual
4. If you have taken a standarized English language examination (i.e., TOEFL, TOEIC, other), please complete the section below:
Name of Examination
Approx. Date Taken
Your Score
5. How did you first hear about UCAELI?
□ Agent
□ Fair
□ Internet
□ Other
6.Are you a student now?
□ Friend
□ Yes
□ Advertisement
□ No
If yes, what grade did you complete? □ High school
□ University
years of study
7. What is your major?
□ Yes
8. Are you a professional (Do you work now?)
□ No
9. If yes, what is your profession (What is your job?)
10. Do you have a college degree? □ Yes
□ No
11. If yes, what is your degree in?
12. Do you want to apply to UCONN or another university in the U.S.? □ Yes
13. If yes, do you want help with the application process? □ Yes
□ No
□ No
14. Would you like to meet a UCONN faculty member to talk about classes you are interested in taking?
V. VISA STATUS
1. If you are currently in the United States, please check ( x ) or explain the type of visa that you have:
□ F1
□ F2
□ US Citizen
□ J1
□ J2
□ Other
2. Are you transferring from another school? If yes, please provide the school name and contact information below and attach a
copy of your SEVIS I-20.
Name of School
Contact
Telephone
SEVIS ID
Ⅵ. VISA STATUS Please fill out this section if your FINANCIAL CERTIFICATION (below) is not in your name.
I, ______________________________, will be the guarantor of financial obligations incurred
(name of the guarantor)
for _______________________________ during his/her enrollment in the UCAELI program.
(name of student)
Signature of guarantor________________________________Date______________________
Ⅳ. FINANCIAL CERTIFICATION
If you need a student (F1) visa, you must show proof of a minimum of $3500 per 4 week summer session.
CERTIFICATE OF (MONEY TRUST) DEPOSIT BALANCE
This is to certify that___________________________________________________________ the
(name of guarantor in this space must be the same name in Section VI under Affidavit of Support)
sponsor for applicant____________________________________________________ maintains
Name of applicant
the following account with______________________________________________________.
Name of bank/institution
Type of account:___________ ___________________________________________________
Minimum deposit of balance as_______________________ is U.S. dollars _________________________＄
Date
Amount
This information is furnished, at the request of the guarantor listed above, without responsibility on the
part of this bank or any of its officers.
Authorized signature___________________________________ Date__________________
Note: Bank may furnish its own letter on bank letterhead in lieu of this form (please attach). Or sponsor may provide a copy of a bank statement showing
the sponsor's name (in English) and the balance in the account in U.S. dollars.
Ⅶ. PRE-PAYMENT AGREEMENT
Student name:
Last Name
First
Application fee:
$
Tuition deposit:
$
Express mail (optional)
$
On-campus housing deposit (optional)
$
TOTAL:
$
Middle
Application Fee: $75 Tuition Deposit: $100 Optional Express Mail: $65 Optional on-campus Housing Deposit: $100
I will pay the above fees by:
1. Credit Card
□ VISA
□ MASTER CARD
□ CISCOVER
I authorize UCAELI to charge the above amount to my credit card.
Credit Card #:
Expiration Date: _______/_________
Name on Card:
Signature:
Billing Address of Cardholder:
2.
□ International Money Order
□ Personal Check from U.S. Bank
Please make checks payable to: University of Connecticut
3.
Wire Transfer
Please remit wire transfers to: Bank of America, Hartford, CT 06103
ABA #: 026009593
Account #: 0000479024
Account Name: University of Connecticut Regular Disbursements Account
Swift/CHIPS: BOFAUS3N/0959 RE: (419131) Att: UCAELI, Neena Kapoor 486-2127
Note: When paying by wire transfer, please be sure to include all bank costs and include the student’s name with your payment.
The following materials are required for processing. Please check that you have enclosed the following information for admissions:
□Fully completed application
□ Application Fee: $75
□Affidavit of Support
□Financial Certification
□Tuition Deposit: $100
□Optional Express Mail service: $65 (Documents will be sent by U.S. Mail if not checked)
□Optional on-campus Housing Deposit: $100 (Refundable until 1week before program start date)
Note: Fees are non-refundable.
If postage for Express Shipping exceeds $65, UCAELI will collect extra postage at time of student registration.
Please make International Money Order or Personal Check payable to the "University of Connecticut."
Mail or fax your application to: University of Connecticut American English Language Institute (UCAELI)
2006 Hillside Road, U-1198
Storrs, CT 06269-1198
Fax: 860-486-3834
Phone: 860-486-2127
E-mail: register-ucaeli@uconn.edu
Website: http://www.ucaeli.uconn.edu