Date of Birth:
(Month)_______________ (Day)________________ (Year)__________________

Country Of Birth_____________________________________________________

Country of Citizenship: ______________________________ Sex: Male [   ] Female [  ]

Mailing Address to which we should send the Form I-20:
 ____________________________________________________________

City____________________State/Province__________________Country_________________

Zip/Postal Code_____________________E-Mail________________________

Telephone: ________________________ Fax: _____________________________

Which session do you wish to begin studies [] Summer   [] Fall I  [] Fall II  [] Spring I   [] Spring II  Year: 20__

How many years have you studied English?  ____________years

Have you taken the Test of English as a Foreign Language (TOEFL)? No _____/ Yes____ Date______ Score_______

Please send me information on health insurance I can purchase in the USA   ________
(Health insurance is mandatory)

Do you want our assistance in making your housing arrangements?
Yes________   Do you smoke?   Yes_____ No_____
No _________ I will make my own arrangements
If you checked 'yes' do you want a roommate? Yes _____ No ______
How much can you pay each month for rent? $___________
Do you want a homestay? Yes_____ No _____
If you checked 'yes' for a homestay, contact Hawaii Homestay directly.

Are you currently in the USA?  Yes_____  No _____
If 'yes', please send a photocopy of your Form I-20 and your USA address and telephone number together with your application form.

What do you plan to do after your English studies?
_____ study in a US college
_____ return to work in home country
_____  other (give details)

Financial Statement  (For F-1 student visa)
Each student enrolling in the IEP who needs an F-1 student visa must provide evidence of adequate financial support to cover all expenses for the period of study in the United States.  Please send us one of the following:

• A current bank statement on bank stationary in your name or your family's name.  If possible, bank statements should be in English with amounts given in US dollars.
• A scholarship award letter in your name.
• A US Department of Justice Affidavit of Support Form I-134 accompanied by financial documentation if you are going to be supported by a US citizenor permanent resident.

Affidavit of Support:
To be completed by the applicant's sponsor:
" I guarantee, without reservation, the maintenance and welfare of ___________________________ and his/her dependents, if indicated, including defraymentof all incidental expenses, requisite travel, and all medical expenses incurred, while the applicant is a student in Hawai'i Community College Intensive English Program.  I further guarantee travel funds for the applicants departure, when such departure becomes necessary.

_____________________________________________
Name of Sponsor
_____________________________________________
Signature of Sponsor
_____________________________________________
Address of Sponsor
_____________________________________________
Relationship to Applicant
 
Amount of financial support required:
If you plan to study for one session only, your bank statement must show at least $5,106 USD.  If you plan to study longer, please multiply that amount by the number of sessions you wish to study.  For example: if you wish to study for four sessions (one year) the financial statement should show at least $21,704.00 USD.
Note:  The Form I-20 will be issued for the length of time that you have quaranteed financial support only.

Before signing this form, please read and check the information below:
______ I have carefullly read this form and completed it accurately.
______ I have encloseed the financial guarantee information.
______ I understand that I must have sufficient funds for tuition and  living expenses during my entire stay.
______ I have enclosed my non-refundable application fee of $75.00  USD made payable to the University of Hawaii.
______ I certify that the information  provided on this application  is correct.
Signature of Applicant____________________________________ Date________________
(You must sign here in English with the name that will be used on the Form I-20.  It must be the name on your passport and other official records)

Please send your application to:
Hawaii Community College
Office of Continuing Education and Training
Intensive English Program
200 W. Kawili Street
Hilo, Hawaii 96720-4091
USA

Application Deadline:
Twelve weeks before the beginning of each session

Checklist:
[] Completed application form
[] $75.00 USD Application fee
[] Financial guarantee information
[]One passport size photograph
[] Completed Student Health History Form
[] Evidence of High School Completion (eg. high school or college transcripts)                         IEP Application  07/2003