Name :
Address :
       City : State : Postal Code :
 Country :
        Tel. : Fax :
   E-mail :
When do you want to come to the US?
     Month :      Year :
Which state or region, e.g. Massachusetts, Midwest?
     Ans -   
What is your English level?
Advanced Intermediate Beginning Other
Have you taken the TOEFL?
Yes No
if Yes, when?
Type:  IBT CBT Pencil and Paper Score (if you remember):
Do you want us to assist with accommodations?
Yes No
If Yes, please specify:
Dormitory Homestay Apartment
Are you interested in distance learning?
Yes No  
Are you studying now?
Yes No If yes, where?
Are you working?
Yes No If yes, where?
What else should we know about you?
Please use the lines below for comments, questions, etc.
     Ans -