Application Form

American English Academy
STUDENT APPLICATION FORM
Reason for Issue*

Initial Attendance = Student is in his countryChange of Status = Change Visa Status in the USATransfer = Transfer from another USA school to American English Academy
A. APPLICANT INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
DO YOU HAVE ANY DEPENDENTS WITH YOU?*

YESNO
Country of Birth*
Country of Citizenship*
HOME ADDRESS*

Street Address

City

CityState

Zip CodeCountry
B) STUDENT ENROLLMENT INFORMATION
Session Start Date*

MonthDayYear
Date
Duration of your stay*

6 months12 months
C) APPLICANT'S FINANCIAL DATA
Funding for Tuition and Living Expenses will come from*

Student's Personal FundsFunds from Other Sources Origin/Explanation of Funds (Submit a sponsorship letter)
REFUND POLICY
- The registration fee is non-refundable.
- 75% tuition refund if students drop out during the first week of classes,
- 50% tuition refund if students drop out during the second week of classes,
- ZERO refund after the second week of classes.
A refund will be credited to the original method of payment within 4 weeks from the day of the request.
DISCLOSURE ACKNOWLEDGEMENT: I am applying for a student visa to improve my English language skills at American English Academy. I fully understand the terms and conditions of my enrollment including refund policies and U.S. Immigration reporting requirements. I am aware that once my visa is approved, information concerning my enrollment and attendance will be reported regularly to the USCIS by American English Academy as required by Federal Law.
Applicant's Signature*

Clear
Today's Date*

MonthDayYear
Date
American English Academy
4749 Main St, Bridgeport, CT 06606, United States
Phone: +1 203-903-7833
hello@americanenglishacademy.edu / www.americanenglishacademy.edu
Should be Empty:

American English Academy

STUDENT APPLICATION FORM

A. APPLICANT INFORMATION

B) STUDENT ENROLLMENT INFORMATION

C) APPLICANT'S FINANCIAL DATA