English As A Second Language Institute Application

Please fill out the requested information below. Do NOT print this page. After completing this form, hit submit below. You will receive and email confirmation. All fields marked with an * are required.

Student Information

*Student Name (as stated on passport, resident alien card or other immigration document)
*Family Name (surname/last name) :  
*First Name (given name) :

Gender
select male female

*When do you plan to begin study?
Summer 2013 (5/6-8/1)
Fall 2013 (9/3-11/27)
Spring 2014 (1/13-4/11)
Summer 2014 (5/5-8/1)
Fall 2014 (9/2-11/25)

*How many terms do you plan to study?
select 1 2 3 4

*Date of Birth
Month None January February March April May June July August September October November December Day None 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

*Country of Birth

*Country of Citizenship

*Home Country Address (required of all F-1s)

US Address (students currently in the US)

*Do you want your acceptance packet mailed to:
home country address
      OR
US address?

*Email Address

*Telephone Numbers
*local
*other (or same as above)

*Visa Information
I will apply for a student visa to enter the US
I am a resident/citizen of the US
I am already in the US and have a visa. Please list visa type and if F-1 visa, indicate SEVIS number and current school name :

*List your native language

*Mark completion level
secondary
university

F-1 students, complete the following information if you have family members requiring an F-2 status:

1. Last name, First name:
   Date of Birth :
   Country of Birth/Citizenship:
   Relationship (spouse/child):
2. Last name, First name:
   Date of Birth :
   Country of Birth/Citizenship:
   Relationship (spouse/child):
3. Last name, First name:
   Date of Birth :
   Country of Birth/Citizenship:
   Relationship (spouse/child):

Required Admission Documents:

• Official transcript (with English translation) from highest education level with proof of completion.
• A non-refundable application fee of $100.00 USD. This will be applied to tuition upon acceptance. Make checks payable to UTChattanooga.
• If resident alien or other immigration status, provide clear copy of immigration document (s).
• F-1 applicants must provide a clear copy of current passport with photo page and expiration date showing. Include copies of family member’s passports if family will accompany you.
• F-1 applicants must also submit official proof of funding to cover tuition and living expenses.
• F-1 applicants who are currently in the US, submit copies of your current I-20, visa, passport, and I-94 card. A good standing statement from your school international advisor is required also.
• Signed signature form.
• Mail all completed application documents to:

Nancy Amberson
International Student Advisor
The University of Tennessee at Chattanooga
Dept. 4755, 648 Oak Street
Race Hall, 206
Chattanooga, TN 37403

Student Cost Estimate for 1, Twelve Week Term:

(Requesting an I-20 for more than one term requires submission of proof of funding for more than one term.)
On-Campus Housing: Contact Student Housing at (423) 425-4304 or visit the web site at www.utc.edu/Administration/StudentHousing/

Statement of Financial Responsibility

US citizens/residents are not required to provide financial information. All others must provide information below:

*How will I pay for the study at the English as a Second Language Institute?
My personal funds (sign signature form and send original bank statement)
My family in my home country (Parent /relative sign signature form and send original bank statement)
Sponsor (sponsor sign signature form and send original bank statement)

**I understand that costs for study and living expenses at the ELI are approximately $5,900.00 for each 12-week term. I accept full responsibility for these expenses.