First Name:

Middle Name:

3. Address:

Address:

City:

State/Province:

Postal Code:

Country:

4. Contact Information:

Telephone:

Fax:

Email: (Required)

5. Personal Data:

a. Date of Birth: Month: Day: Year:

b. Country of Birth:

c. Citizenship:

d. Native Language:

e. Gender: ---MaleFemale

f. Marital Status: ---MarriedSingle

6. Will your spouse accompany you?  Yes No

a. Name of Spouse:
b. Date of Birth: Month: Day: Year:
c. Country of Birth:

7. Will your children accompany you?  Yes No

1a. Name of Child:
1b. Date of Birth: Month: Day: Year:
1c. Country of Birth:
1d. Gender: ---MaleFemale

2a. Name of Child:
2b. Date of Birth: Month: Day: Year:
2c. Country of Birth:
2d. Gender: ---MaleFemale

3a. Name of Child:
3b. Date of Birth: Month: Day: Year:
3c. Country of Birth:
3d. Gender: ---MaleFemale

8. Person in the United States (if any) we may contact concerning your arrival:

a. Name:
b. Address:
c. Telephone:

9. Are you NOW in the United States?  Yes No

a. If your answer is yes, when did you come to the United States? Month: Year:
b. What type of visa do you hold?

(Note: If you are transferring to the L.E.A.P. Program from a school in the United States, please send us a photocopy of the I-20 you currently hold)

10. If you are not in the United States at this moment, do you wish to be sent an I-20 for a student Visa?  Yes No

a. If no, on which Visa do you intend to enter the United States?

11. Are you being sponsored by an agency or embassy to study in the United States?
 Yes No

a. If yes, what is the name of the organization?

12. Educational Objective in the United States:
 Language Training Only Undergraduate Study Graduate Study

13. If you are planning to study as an undergraduate or graduate at an American college or university, what will be your major area of study?

14. Have you been admitted to an American college or university?  Yes No