UNIVERSITY of HOUSTON
LANGUAGE and CULTURE CENTER
INTENSIVE ENGLISH COURSE APPLICATION FORM
I. Calendar
For which semester are you applying?
__ Fall __ Spring __ Summer __ Summer II Year 2010
2011
II. Summary of Costs*
Spring (14 weeks) Summer II (7 weeks)
Summer (13 weeks)
Fall (14 weeks)
Application fee (Non-refundable) $ 100.00 $ 100.00
Program Tuition and Fees 2345.00 1180.00
University fees 340.00 193.00
Medical insurance 171.00 87.00
TOTAL $ 2,956.00 $ 1,560.00
Late Registration $ 50.00
(There is only one Registration Day per term. The late fee is charged after
this day. There is no late registration permitted for the 7-week term.)
Books and supplies (approx.) $ 150.00 $ 150.00
*All prices are subject to change without notice.
III. Applicant Information
1. Applicant's name: _______________________________________________________
Last (Family) First Middle
2. Sex: __ Male __ Female
3. Native language: ____________________________
4. Country issuing passport: ____________________________
5. City and country of birth: ____________________________
6. U.S. permanent resident: __ Yes __ No
7. U.S. citizen: __ Yes __ No
8. Date of birth: __________________
Month Day Year
9. Date of high school graduation: __________________
Month Day Year
10. If married, name of spouse: ____________________________________________
First Middle Last (Family)
11. Address and telephone number in your country:
______________________________________________________________
Number & Street Apartment number
______________________________________________________________
City State/Province/Country Postal code
Telephone number: ___________________________
12. Address in the United States, if any, care of:
______________________________________________________________
First Middle Last (Family)
______________________________________________________________
Number & Street Apartment number
______________________________________________________________
City State/Province/Country Postal code
Telephone number: ___________________________
13. Applicant's email: ________________________________________________
14. Applicant's signature: ________________________________________________
IV. Housing
If you are interested in living in the University of Houston residence halls,
please refer to the following page for more information:
http://www.housing.uh.edu/
V. Visa Information (Important-fill in carefully)
A. For all students: A student visa (F-1) or other acceptable classification
is necessary in order to study full time in this program.
1. After you study intensive English, in what subject do you plan to major?
___________________________
2. Which is the first level of education you plan to obtain in the United
States after the intensive English program?
__ High School __ Undergraduate __ Graduate-Master's __ Graduate-Ph.D.
__ Language training only __ Other: ___________________________
B. For students outside the United States only: If you are coming to the U.S.
from another country, you must enter the U.S. using the I-20 form from the
Language and Culture Center in order to attend our program.
1. Will you enter the U.S. on a student visa (F-1)? __ Yes __ No
If no, what type of visa will you have? ___________________________
2. Do you need an F-2 visa for your spouse and/or children? __ Yes __ No
If yes, please write the name of your spouse and/or children:
Spouse's name: _______________________________________________________
Last (Family) First Middle
Spouse's country of birth: ___________________________
Spouse's gender: ___________________________
Spouse's Date of birth (Month/Day/Year): ______________________
First child's name: _______________________________________________________
Last (Family) First Middle
First Child's country of birth: ___________________________
First Child's gender: ___________________________
First Child's Date of birth (Month/Day/Year): ______________________
Second child's name: _______________________________________________________
Last (Family) First Middle
Second Child's country of birth: ___________________________
Second Child's gender: ___________________________
Second Child's Date of birth (Month/Day/Year): ______________________
Third child's name: _______________________________________________________
Last (Family) First Middle
Third Child's country of birth: ___________________________
Third Child's gender: ___________________________
Third Child's Date of birth (Month/Day/Year): ______________________
Fourth child's name: _______________________________________________________
Last (Family) First Middle
Fourth Child's country of birth: ___________________________
Fourth Child's gender: ___________________________
Fourth Child's Date of birth (Month/Day/Year): ______________________
C. For students inside the United States only:
1. What type of visa do you currently have? _________________________________
2. Are you transferring from another school in the U.S.? __ Yes __ No
If yes, what is the name of the school? __________________________________
3. Are you changing to F-1 Visa? __ Yes __ No
4. Transfer students must submit:
A SEVIS transfer release form including:
a. verification from their current school showing that they have
maintained their immigration status and are eligible to transfer, and
b. a copy of their I-20 form from their current school.
VI. Financial Support
1. Print or type sponsor's full name, address and telephone number:
______________________________________________________________
First Middle Last (Family)
______________________________________________________________
Number & Street Apartment number
______________________________________________________________
City State/Province/Country Postal code
Telephone number: ___________________________
2. Sponsor's relationship to student: ___________________________
3. You must submit proof of adequate financial support for study in the U.S.
before you can be issued an I-20. Acceptable proof is 1) an I-134
Affidavit of Support or a letter signed by your sponsor verifying
sponsorship, or the sponsor's signature after the statement in #4 below
and 2) proof of the sponsor's financial resources, for example, a letter
from the sponsor's bank or the sponsor's tax records. (If you are over 21
and have the funds to support yourself, you do not need a sponsor, but you
must submit proof of your financial resources.)
4. Statement of Financial Support. This is to certify that I will assume
full financial responsibility (a minimum of $6,786 US per 13 or 14-weeks term) for the
support of _______________________________________ while attending the
University of Houston Language and Culture Center.
______________________________________________________________
Sponsor's signature Date
5. Authorization
I certify that the information on this application is complete and correct.
I authorize the University of Houston Language and Culture Center to verify
all information included in this application. I authorize the University of
Houston Language and Culture Center to release information about my studies
to my parents, guardian and/or sponsor, whose name appears above.
______________________________________________________________
Applicant signature Date
(This application is valid for one year from date of receipt of the
application fee. After that date you will need to submit new financial
support documents and repay the application fee if you wish additional I-20s.)
Mail this application, together with an official copy of your transcript and
graduation diploma (with English translation), financial support documents, a
photograph (attached below) and the non-refundable application fee of
$100.00 (check or money order only made payable to the "University of Houston").
Mailing address:
_________________
To Language and Culture Center | |
116 R. Cullen Building | Please attach |
University of Houston | a photograph |
Houston, Texas 77004-3014 | here to assist |
U.S.A. | in participant |
Phone: (713) 743-3030 | identification. |
Fax: (713) 743-3029 |_________________|
