CPELI Academic Studies Program Application for Visiting Students A program sponsored by the Cal Poly Pomona Foundation

Transcription

1 CPELI Academic Studies Program Application for Visiting Students A program sponsored by the Cal Poly Pomona Foundation Family Name First Name Middle As it appears on your passport Gender: Male Female Date of Birth: (month/day/year) Applicants should be high school graduates. Program Choice: Summer 2015 Fall 2015 Winter 2016 Spring 2016 Country of Birth: Country of Citizenship: Address in home country: Mailing Address: address: Phone: Are you currently studying in the U.S. on an F-1 visa? Yes No If yes, please list your current school: Academic History: Applicants with less than 2 years of completed college/university coursework must include high school information School Name City, State, Country Language of Instruction Grade System (Letter or Numeric) Begin Date End Date Diploma/Certificate and Date of Completion Please list any standardized tests that you have completed or plan to complete. (SAT/ACT, SAT Subject Exams, GRE/GMAT, TOEFL, or IELTS) Testing Date Score Date Score Date Score

2 Will any dependents (spouse/children) accompany you to the United States? Yes No If yes, list below and send a passport copy for each individual. Last/Family Name First Name Middle Name Date of Birth Spouse or Child Refund Policy I have read and acknowledge the refund policy below. Tuition and fees can only be refunded upon request of the following BEFORE the program start date as clearly indicated on your I-20: a written request for withdrawal from the program and the original I-20 issued by the Cal Poly English Language Institute. No refunds will be granted AFTER the program start date. Refund requests take six to eight weeks to be processed. Program application fees are non-refundable. Student Certification and Signature I certify that the information in the entire form is correct to the best of my knowledge. Please check off the following items with your application: CPELI Enrollment Application non-refundable fee of $150. (Payable by AMEX, VISA, MasterCard or money order). Copy of your Passport ID page. Copy of all high school and/or Undergraduate transcripts translated in English. Copy of your Official TOEFL or IELTS score report and results from any other examinations you have completed. Financial support statement along with a bank statement with funding of at least $26,300 USD from the person sponsoring you studies in the U.S. Statement of Purpose CPELI Representative Information: Company Name: ID# Contact Name: Address: Phone/Fax: City, State, Zip Code: IMPORTANT For Sponsored Students: Our office receives requests from your agent/representative to release your applications status, financial and academic information. Under CPELI policy, your written consent is required to release and information to a third party. By signing below, you authorize the release of the above information. Student

3 Statement of Purpose Please state your specific interests with respect to the program to which you are applying: 1-2 pages is fine. Use additional pages if needed. In an essay, discuss how your personal background informs your decision to study in the CPELI Academic Studies Program. Please include any educational, familial, cultural, economic, or social experiences, challenges, or opportunities relevant to your academic journey and how you might contribute to social or cultural diversity within your chosen field.

4 Return this CPELI Application with application fee to: Cal Poly English Language Institute California State Polytechnic University, Pomona 3801 West Temple Avenue, Bldg. 86 Pomona, CA Telephone: Fax: Website: Financial Statement: Complete this section if you are requesting Form I-20 for the student visa. The United States Immigration and Customs Enforcement (ICE) requires that all applicants be able to pay tuition charges and living expenses while studying in the United States. Therefore, you must show that you have funds available to study before you come to the United States. Please complete the appropriate section below: 1. If the applicant will be self-supporting: or I certify that I have sufficient funds available to support all educational and living expenses during the entire period of my study at Cal Poly Pomona. I have attached an original or certified copy of a bank statement in English which shows my name, the funds available for study in U.S. currency and a bank official s signature. Applicant s signature: 2. If the applicant will be provided funds by guarantor: This is to certify that I guarantee all school, living, and personal expenses for the applicant named above during his/her entire period of study at Cal Poly Pomona. I have attached an original or certified copy of a bank statement in English which shows the guarantor s name in English, the funds available for study in U.S. currency and a bank official s signature. Complete Name of Guarantor/Sponsor: Relationship of Guarantor to Student: Parent Guardian Sponsor Guarantor s signature: Student s Representative: 1. Are you working with an agency? Yes No If yes, please state the name of the agency: 2. Are you studying with a group or university? Yes No If yes, please state the name of group or university: 3. Are you a family member submitting documents on behalf of the student? Yes No If yes, please state name of person: If a person other than the applicant will be receiving the student s information or documents, you MUST complete page three (Student Consent for Release of Information) of the application. I verify that the information contained in this application is accurate to the best of my knowledge. I attest to having at least 2 years of high school level English Language instruction. I acknowledge that during my study at Cal Poly Pomona I will not be permitted to work off campus. PRINT/TYPE THE NAME OF STUDENT OR STUDENT S REPRESENTATIVE REQUIRED Application Documents: Signed & Completed Application Copy of Passport Bank Statement (English copy within 6 months) $150 Application Fee Student Release of Information Form (optional) SIGNATURE OF STUDENT OR STUDENT S REPRESENTATIVE A self-support program of Cal Poly Pomona Foundation, Inc. administered by the College of the Extended University at California State Polytechnic University, Pomona.

5 California State Polytechnic University, Pomona 3801 West Temple Avenue, Pomona, CA fax Cal Poly English Language Institute College of the Extended University STUDENT CONSENT FOR RELEASE OF INFORMATION I understand that if I am admitted and enroll at CPELI, the federal Family Educational Rights and Privacy Act of 1972 (FERPA) protects the privacy of my education records. As a prospective student, I also may have rights under the laws of the United States, the State of California and/or my country of residence protecting the privacy of records I give to CPELI and/or third parties in connection with my application to enroll as a CPELI student. By signing this form, I,, hereby waive any rights described above and give my consent to CPELI and the person / agency named below to disclose my application and any other education records to each other for the purpose of discussing my application to, admission status and educational experience at CPELI: Name of Advisor/Person: Name of Organization/Agency: Address: Phone Number: Address: I understand that I have the right not to consent to the release of information in my student records and that I may revoke this consent at any time by giving written notice to CPELI and the person / agency named above. This consent remains valid unless and until I revoke it. Prospective Student Prospective Student Name (print): If Prospective Student is under 18 years of age: I am the parent or legal guardian of the Prospective Student. I am signing this document on his or her behalf. Parent or Guardian Parent or Guardian Name (print): CEU