A. PERSONAL INFORMATION

Email Address:

Family Name:    

First Name:       

Birth Date (Month/Day/Year):

Male   Female

Country of Citizenship: 

Country of Birth:          

City of Birth:                

Type of visa you will study on:

F-1 Student Visa Information

Visa Waiver B2 Visitor Visa F1 Student Visa Other

How did you hear about ICC?

B. HOME COUNTRY ADDRESS

Street Address:

City or town: 

State or Province or Prefecture

Country:

Zip Code/ Postal Code

Telephone (Include country and area codes)

C. NEXT OF KIN/EMERGENCY CONTACT PERSON

First Name:

Family Name:

Relationship:

Complete Address:

Home Phone: Work/Cell Phone:

Email Address:

D. STUDYING AT ICC

Registration Start Date:    Registration End Date:

View our term calendar for start dates.

Program of Study:

English For Communications (EC) Business English Certificate (BEC) TOEIC Examination Preparation TOEFL/University Bridge Program Cambridge Program (FCE, CAE, CPE) Cambridge Intensive Program (FCE, CAE) Internship Program CELTA Teacher Training Course Private Lessons

Current Level of English:

Beginner Intermediate Upper Intermediate Advanced

E. ACCOMMODATIONS: Please provide a first and second choice of accommodation in case your first choice is unavailable.

Accommodation start date:  

Accommodation finish date:

First Choice of accommodation:

No accommodations Homestay Hotel or studio apartment Dormitory Apartment

Second Choice of accommodation:

No second choice Homestay Hotel or studio apartment Dormitory Apartment

Please include with your application:

a. Would you like us to express mail your I-20?  (This requires an additional fee of $50-$100.)
Yes No

b. Would you like us to make your $200 SEVIS payment to the Department of Homeland Security? (The I-901 SEVIS fee will be charged to your credit card. You can also make the payment yourself at www.fmjfee.com. More information about the fee can be found at http://www.ice.gov/sevis/i901/index.htm).
Yes No

F. CONDITIONS OF ENROLLMENT AND REFUND POLICY

I have read and agree to be bound by the Refund and Cancellation Policy    Yes

G. STUDENT AGREEMENT

I certify that the information provided on this application form is correct. I fully understand that persons coming to the US on a student visa are expected to study full-time. I understand that if I decide not to attend ICC, I must return my I-20 form (if full-time) to the school to get a full refund. I have read and understand the information in this enrollment agreement, and the ICC cancellation and refund policy.   By signing this agreement, I authorize ICC to credit my account if the deposit is greater than my initial tuition and fees. I understand that ICC has the right to change policies, prices and programs without prior warning. All information on this form is true and accurate to the best of my knowledge. This contract is legal and binding.

Student's Name:         Date:

Guardian's Name (if under age 18):       Date:

Authorized ICC agent's name:     Date:

H. Notes

I. Travel Agent name (if you are an agent please write your name here):

Fill out this application and then select the Submit button below. Press submit only once. If you make a mistake before submitting return to the section and change it. If you wish to erase all information and start over press the reset button.