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Intensive English Program

Language Institute
Section 1: Personal Information
Full Name:
Last (Family) First Middle Month/Day/Year Country of birth Country of citizenship Native language

Application Form 2011-2012

Sex:

Male

Female

Date of Birth:

Permanent Foreign Address:


Number/Street City State Country Postal Code

Local U.S. Address (if available):


Number/Street City State Zip Code

Contact Information:
Telephone (Where you can be reached) Fax Email

Section 2: Visa Information


Do you presently have a United States Visa? Do you plan to apply for an F-1 Student Visa? If yes, what school issued your I-20? Are you a United States permanent resident? Yes Are you a United States citizen? Yes Have you applied to a Georgia Tech degree program? If yes, what is your GT ID? No No Yes Yes Yes No No
If yes, what type?

Are you currently in the United States with an I-20 and plan to transfer?

Yes

No

No

Section 3: How did you hear about Georgia Techs Language Institute?
Former student
Name:

Agency

Please specify:

A friend told me about it Study in the USA website International study fair in my country

A family member told me about it Georgia Tech website Other


Please specify:

Section 4: Which session do you plan to attend?


Summer 2011
(June 6 Aug 5)

Fall 1 2011
(Aug 22 Oct 14)

Fall 2 2011
(Oct 24 Dec 16)

Spring 1 2012
(Jan 9 Mar 2)

Spring 2 2012
(Mar 12 May 4)

For Non F-1 Students Do you wish to study full-time or part-time? Which courses would you like to take? For Part-time Students

Full-time Part-time Grammar Writing Reading

Speaking/Listening Morning Afternoon

What time of day do you prefer to study?

Section 5: What is your main reason for studying English in the U.S.?
to prepare for undergraduate study in the U.S. to prepare for graduate study in the U.S. to get a better job for social reasons other:

Section 6: Statement of Financial Eligibility (for F-1 Visa Students)


Fill out this section only if you are requesting a SEVIS form I-20. All students requesting an I-20 must demonstrate evidence of financial support for their stay in the U.S.

Financial declaration: The approximate cost of one 8-week session at the Language Institute Intensive English Program is $4,652. This cost includes tuition, fees, books, accommodations, insurance, and meals on campus. An additional $1,000 per session is required for each dependent included on the Form I-20. Please include a bank letter. See Instructions for preparing a Bank Document on our website. Name and address of person or organization responsible for the payment of your expenses:
Last (Family) City First Country Address Postal Code Telephone Fax

Do you want to include your spouse and/or children on the SEVIS Form I-20? Yes No If yes, please provide the following information and submit a copy of the passport I.D. page for each person (Attach additional
sheets if necessary)

Name: Date of Birth:


Month/Day/Year

Relationship: Country of citizenship: Country of birth:

Section 7: Emergency Contact (Who should we contact in case of an emergency?)


Name: Relationship: Address: Telephone: E-mail: Send application documents by: Fax to: 404-894-8755 or Mail to: Language Institute Georgia Institute of Technology 151 6th Street, NW Atlanta, GA 30332-0374, USA

Section 8: Application Documents


1. Completed and signed application form 2. Nonrefundable application fee of US $100 3. Copy of passport I.D. page for applicant and dependent(s) 4. Required medical documents 5. Bank document (for F-1 Visa Students) 6. US $50 international mail fee 7. Transfer clearance form. (Transfer students only)

Section 9: Where do you want us to mail your I-20 and acceptance package?
Name City State Number/Street Country Postal/Zip Code Telephone

Section 10: Signature


Before signing this form please read the following carefully and check the boxes next to the statements. If I enroll in the IEP, I agree to follow the Georgia Tech Student Conduct Code. Details can be found at http://www.deanofstudents.gatech.edu/osi I understand that the application for admission to the Intensive English Program does not constitute or guarantee admission to any Georgia Tech degree program. I understand that I do not choose my level. My level will be based on my placement tests score. I certify that the statements on this form are complete and accurate. My signature below indicates that I am registering for this course and am responsible for full payment of all the costs for the IEP program.
Signature of applicant Date Signature of sponsor Date

If you have questions about your application call 404-894-2425 or e-mail apply@esl.gatech.edu

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