Instrucciones:

1. Check when you plan to begin studies at the Institute:

Fall ____ Spring ____ Summer I ____ Summer II _____  Summer III _____ 

Short-Term __________ (Dates: from ______________to_____________)

2. Name _________________________________________________
 family name               first                      middle               maiden (married woman)

3. Address
__________________________________________________________
street number and name                                                    apartment number

______________________________________
city                                      state/province                                
_____________________________________
      country                          zip or postal code

4. Home Phone: ___________________    
Fax (if available) _______________________    

Work Phone: _____________________    
Fax (if available) _______________________

E-mail Address: _______________________________                                                     

5. Mail admission materials via:

Regular mail ________    Express mail ________   
(The student will be charged for express mailing.)

6. Syracuse area telephone contact ____________                                                              

7 . Sex: Male:_____   Female:  _____        

8. Date of birth _____________________________________
                              month               day                year

9. Country of birth ___________  
Country of citizenship ______________

10. Single ____   Married ____

Will your spouse accompany you? Yes ____    No ____

If yes, please provide:

Spouse's Name__________________________________
Date of Birth______________________________
Country of Citizenship______________________________
Country of Birth___________________________________

11. Will children accompany you?      Yes ____    No ____

If yes, please provide:

Child's Name_____________________________________
Date of Birth______________________________
Country of Citizenship______________________________
Country of Birth____________________________________

12. Do you desire on-campus housing?      Yes ____   No ____   

single ____   double ____   2-bedroom apartment _____

Please complete separate housing application.  

13. Are you applying for a student visa with this application?    

  Yes ____    No ____   

14. If currently in the United States, what type of visa do you hold?

Student _____ Exchange _____ Visitor _____

Tourist ____ Other_____

15. Education

(highest level completed-secondary or university) ____________________

16. Language(s) spoken __________________________

17. Are you enrolled in another American Institution?  

 No ____  Yes (name)____________

18. Have you studied English at another institution?  

No _____ Yes (name)____________

19. Have you taken the Test of English as a Foreign Language? 

No ____ Yes_____ Date ____________ Score _________  

20. What do you plan to do after completing intensive English studies?

____________________________________

21. Major field of study:

Undergraduate _________________

Graduate _______________________

22. Profession ______________________________

23. Please indicate your knowledge of English with a check mark:

24. How did you hear about the ELI at Syracuse University?

________________________________________________

25. Financial Statement (certified bank statement must be included):

    a. Name and address of parent, guardian, or sponsor(ing agency) (unless self-supporting)

       _______________________________

    b. Signature of parent, guardian, or sponsor (unless self-supporting)

___________________________________

   c. This is to certify that I am aware of the costs for the English Language Institute at Syracuse University. I have funds available as required. I also understand that tuition is not refundable after the first day of the semester.

Signature of applicant_______________________________________

Date___________

  Health Insurance is mandatory and can be purchased at the English Language Institute