APPLICATION FORM and PRE-PAYMENT AGREEMENT
APPLICATION FORMBe sure to complete both sides of this form
Name:______
Last or SurnameFirst or GivenMiddle
Home Country: ______Present Address: ______
Address:______
______
______
Telephone: ______Telephone: ______
Cell: ______Student E-mail: ______
Contact Address:______
______
Contact Telephone: ______E-mail: ______
Country of Birth: ______ Male Female Date of Birth: _____/_____/_____ (Month/Day/Year)
Country of Citizenship: ______Native Language: ______
• Highest degree awarded: High school diploma (must send) Bachelor’s Master’s Other ______
• If in U.S., please circle current status:F-1F-2J-1J-2Other ____Permanent Resident ____ U.S. Citizen ____
• Student Visa (Form I-20 required): Yes (Attach a copy of your passport) No
• How would you rate your English: Beginner Intermediate Advanced
• Have you taken the TOEFL exam? No Yes
If Yes: Date of exam: ______/______/______(Month/Day/Year)Score: ______(Please send official score)
• Check all semesters you would like to attend. (Please send a copy of your passport)
Fall 2017 16 weeks August thru December Summer 2017 Spring 2018 16 weeks January thru May
Please see CCSU’s Website for Dates
• I prefer to live on campus• I prefer to live off campus, send me a list of apartments in the area
• How did you learn about us? a professional recruiter ______ a guide book ______
an internet website ______ a newspaper ad ______
the phone book a friend/relative other source ______
“I understand that when I register for any class at Central Connecticut State University or receive any services from Central Connecticut State University, I accept full responsibility to pay all tuition fees, and other associated cost, which may include, but is not limited to, housing, meals, fines, or incidental charges assessed as a result of my course/housing registration and/or receipts of services. “
A non-refundable deposit for $125 is required to process your application. The $125 will be deducted from your total tuition.
Please send check or money order, payable to “CCSU”, Mail to:Central Connecticut State University/IELP
1615 Stanley Street
Henry Barnard Hall, #5, Room 124
New Britain, CT 06050, USA
______
Signature of Applicant Date
PRE-PAYMENT AGREEMENT
Term: ______Date: ______
Student’s Name:______
LastFirstMiddle
Non-refundable Tuition Deposit:$125
______
1.) Please use the IELP website below to make your deposit payment:
2.) Other payment options:
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Intensive English Language Program
Central Connecticut State University
1615 Stanley Street,
Henry Barnard Hall #5, Room 1240000
New Britain, CT 06050 USA
Telephone: 860-832-3376
Fax: 860-832-3377
E-Mail: