Page 1. Jamestown Community College. English Immersion Program Application

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1 Page 1 English Immersion Program Application International Outreach Office 525 Falconer Street Jamestown, NY Phone: Fax: rev

2 English Immersion Program Instructions & Information Page 2 The English Immersion Program application for admission must be completed and signed by the applicant only. The completed application must include: Photocopies of your passport and visa are required upon arrival to the college. A verified official statement of financial resources in U.S. dollars available to support your education and living costs in the United States for the duration of the English Immersion Program, if applying for an F-1 visa. ATTENTION APPLICANTS SEEKING STUDENT VISAS: For detailed information on this process, go to ADDITIONAL INFORMATION: No TOEFL is required for the English Immersion Program. Payment may be made by credit card or wire transfer. Please contact international@mail.sunyjcc.edu for more information regarding payment. Applicants should complete admissions procedures and submit all documents by June 15. SCAN AND COMPLETED APPLICATION TO: international@mail.sunyjcc.edu OR MAIL TO: International Outreach Office 525 Falconer Street, P.O. Box 20 Jamestown, NY U.S.A. s English Immersion Program is open to individuals 16 years and older. A participant in the English Immersion Program does not have to enroll at or be a student at a college or university in the United States.

3 English Immersion Program Application You must include copies of your passport, visa, and I-94 card. Page 3 1. Legal Name (exactly as it appears on your passport) 2. Date of Birth / / Family name First Middle Month Day Year 3. Male Female 4. Phone number daytime evening 5. Permanent Address (in your country) No. and street; cannot be a post office box Town or city Province or State Country Zip code 6. Present Mailing Address (if different No. and street; cannot be a post office box Town or city from above) Province or State Country Zip code 7. Information regarding your application should be sent to which address? If your education records are filed under a different name, show your former name: Family name First Middle 9. If you are married, is your family accompanying you? Yes (If yes, complete section below and attach copies of passport information for each.) No Name of family member Relationship to applicant Gender Date of birth 10. Country of Citizenship (list all that apply) 11. Place of Birth Province or state Country 12. address 13. Will you be seeking an F-1 Student Visa? Yes No 14. Will you be seeking on-campus student housing? Yes No

4 Page 4 English Immersion Program Application 16. What are your plans upon completion of English studies? 17. Date you expect to arrive in the United States / / Month Day Year 18. Do you have any physical disabilities for which you require special accommodations? Please describe. 19. How did you hear about? Friends/relatives Community organization College website/internet Other PLEASE NOTE: New York state law requires that sickness insurance, repatriation insurance, and evacuation insurance be carried by all international students. Current policy provides that this expense be paid at the same time tuition is due. PLEASE READ CAREFULLY AND SIGN BELOW I certify that the information given in this credential is complete and has been completed by me and accurate to the best of my knowledge. I agree to comply with any necessary regulations and return to my home country upon the completion of my studies in the United States. I understand that any knowing or intentional falsification of the information I submit may be grounds for summary dismissal from my studies. Furthermore, I have read and I understand all the information provided on this application. I understand that if I am filling this application out on a computer, then my signature is simply my name, typed by me on my keyboard, and that once I type in my name and the date it will count as my electronic signature. Signature Date

5 Declaration of Finances For Applicants Seeking An F-1 Student Visa If you are seeking an F-1 visa, you must submit the following information. Your Certificate of Eligibility (I-20) will not be authorized until this form is completed and returned to the college. Enter amounts in U.S. dollars ($). Page 5 STUDENT S SOURCE OF FUNDS ASSURED PERSONAL SAVINGS 1ST YEAR 2ND YEAR NAME OF BANK A bank official s signature is required on The certification if the student is partially or totally supported by personal savings. FAMILY SAVINGS NAME OF BANK Enclose with this form a signed copy of your letter of support, and current bank statement. SPONSOR/GOVERNMENT ATTACH OFFICIAL BANK STATEMENT(S) IN U.S. DOLLARS Parent/guardian s signature is required Signature of Parent Address NAME OF SPONSOR/AGENCY Enclose with this form a signed copy of your letter of support, and current bank statement. OTHER (SPECIFY) i.e. scholarships, loans Date What is the total amount you expect to have when you arrive at this institution? Do you plan to attend summer school? Do you plan to remain in the U.S. during the summer? U.S. $ Yes No Yes No Enclose with this form a signed affidavit from an authorized person to certify the accuracy of this entry. TOTAL $ $ What are the sources and amounts of support available to you during the summer? (List the sources and amounts below) SOURCES: U.S. $ U.S. $ U.S. $ VERIFICATION: A. This is to certify that the funds indicated above are on deposit or are being held in the name of the applicant, his family members, or sponsors (named above) at the savings institution named below. (Verification of amounts is without liability for the bank or its officials.) Attach separate statement of accounts with official signature/seal. Name of Bank Bank Official s Title Date Bank Official s Signature/Seal B. This is to certify that I (we) the undersigned have agreed to provide the funds indicated above to the applicant for the purpose of full-time study at the State University campus listed above and that I (we) are submitting bank statements indicating the availability of these funds. I (we) further understand that the State University cannot provide ANY financial assistance to the applicant and that I (we) must provide these funds for the duration of the applicant s course of study. If the commitment is not met, the student may be subject to dismissal from the University for non-payment. Sponsor Signature Date Sponsor Signature Date Relationship to applicant Relationship to applicant C. This is to certify that the information given on this form is complete and accurate to the best of my knowledge. I am fully aware that any false or misleading statement will result in an automatic denial of admission, or cancellation of registration following enrollment. Applicant Signature Date Relationship to applicant I certify that the information provided here is correct and complete. WARNING: Providing false information may jeopardize a student s visa status and furthermore may result in an institution revoking its initial decision to enroll the student. SIGNATURE OF STUDENT DATE