Personal Information

Name:

                     Family Name                          Given Name(s)

Name as written on your passport:

Current Address:

Permanent Address (if different):

Telephone Number:

   Include country and city code

Fax Number:

   Include country and city code

E-mail Address:

Date of Birth:    / /         Age:
                              Day        Month        Year

Sex:   Male         Female

Country of Birth:

Country of Citizenship:

Native Language:

How long have you studied English?

What is your current English level? (Select one)
Novice                       Beginner     Low Intermediate
High Intermediate    Advanced    High Advanced

 Emergency Contact
    (A family member or friend)

Name:

                     Family Name                          Given Name

Relationship to Student:

Telephone Number:

   Include country and city code

Address:

  Student and Visa Information

Are you now in the United States? Yes      No

If yes, when did you enter?
Month:     Year:

If no, when will you enter?
Month:     Year:

Why do you want to study English in the United States of America?

What type of visa do you hold or want to hold?

How many sessions do you want to study at ECI ELP?

When do you want to start class? (Select more than one of the start dates if you are going to study for more than one session)
15 September 2003       13 October 2003     10 November 2003
10 December 2003       19 January 2004     16 February 2004
15 March 2004              19 April 2004          17 May 2004

Program Type for Internationals (Student Visa)
Semi-Intensive (18 academic hours, no electives)
Intensive (24 academic hours, including electives)
Additional one-on-one tutoring (check for prices)

Program Type for Domestic Students (non F-1 Students)
Semi-Intensive (18 academic hours, no electives)
Intensive (24 academic hours, including electives)
Single Course:
Additional tutoring