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I. Instructions
With this application, please enclose:
a. An official copy of your high
school or university grades;
b. An official financial support
statement from your bank, sponsor or guardian, certifying that
you have
at least US $4,000 available for your first term at INTERLINK;
c. $100.00 non-refundable application
fee;
d. A non-refundable security
deposit as specified below:
| Colorado School of Mines | $50 |
| Indiana State University | $35 |
| Valparaiso University | $50 |
| University of North Carolina | $100 |
| INTERLINK Language Center
Colorado School of Mines Golden, Colorado 80401 Tel: (303) 273-3516 Fax: (303) 273-3529 [email protected] www.mines.edu/Outreach/interlink |
INTERLINK Language Center
Indiana State University Terre Haute, Indiana 47809 Tel: (812) 237-8026 Fax: (812) 237-8031 [email protected] http://web.indstate.edu/interlink |
| INTERLINK Language Center
The University of North Carolina at Greensboro Greensboro, N.C. 27402-6170 Tel: (336) 334-4700 Fax: (336) 334-4701 [email protected] www.uncg.edu/ipg/interlink |
INTERLINK Language Center
Valparaiso University Valparaiso, Indiana 46383-6493 Tel: (219) 464-5518 Fax: (219) 464-6846 [email protected] www.valpo.edu/interlink |
II. Personal Data
1. ______________________________ ______________________________
Family Name
First Name
2. __________________________________________________
Mailing Address (PO Box or Street No.)
____________________________
______________________
City/State or Province/Country
Postal Code
____________________ ____________________
________________________________
Telephone Number
Fax Number
E-mail address
3. Date of birth: _______________
Day/Month/Year
4. Country of birth: ________________________
5. Country of citizenship:______________________
6. Where do you wish to study?
___ Colorado School of Mines
___ Indiana State University
___ The University of North Carolina at Greensboro
___ Valparaiso University
7. How long do you plan to study at INTERLINK?
_________________ Number of weeks
8. When do you wish to begin your studies at INTERLINK?
( ) January ( ) March ( ) May ( ) June/July ( ) August ( ) October
( ) 2003 ( ) 2004 ( ) 2005
9. After attending INTERLINK, what do you plan to do?
Study for: ( ) a. BA/BS ( ) b. MA/MS ( ) c. PhD Academic field or major _______________________
( ) Return home ( ) Travel in the U.S. ( ) Other: ______________________
10a. How do you rate your English language skills:
( ) Very good ( ) Good ( ) Fair ( ) Poor ( ) None
Note: Elementary levels at INTERLINK assume knowledge of basic grammar and some communicative ability.
10b. Have you taken the TOEFL or Michigan Test? ( ) Yes ( ) No
If yes, write the date _____________________ and your score ________________________
11. Where or from whom did you first hear about INTERLINK?
__ The INTERLINK homepage on the Internet
__ _____________________________________________
(Please specify name of person, agency, organization, or publication)
__ INTERLINK advertisement _____________________
(specify publication)
__ Other: ______________________________________
(Please specify)
III. Housing Information
12. Please rank the following housing options in order of preference
(1= your first choice;
2 = your second choice, etc.):
_____ University residence Hall _____ Host Family _____ Apartment
13. Please check below the appropriate sections which apply to you:
A. ( ) Male
( ) Female
B. ( ) Single
( ) Married
C. ( ) Smoker
( ) Non-smoker
If married, will your family accompany you? ( ) Yes ( ) No
If "Yes," send us complete name, date, place of birth,
and country of citizenship for each family member.
IV. Health and Financial Information
14. Do you have any physical disability or health problems that will require special assistance?
( ) Yes ( ) No If yes, please explain: __________________________________________________
15. Who will finance your education in the US?
( ) Self ( ) Family ( ) Government ( ) Other (Please specify): _______________
16. Please indicate the type of visa you will have:
( ) Student (F-l) ( ) Exchange Visitor (J-l) ( ) Other (Please specify): _______________
17. Do you wish to receive your admission materials via express mail? ( ) Yes ( ) No
NOTE: The charge for this service is $50. You may send a check for $50 or allow INTERLINK to charge it to your credit card.
18. You may pay for your tuition and application fee by Visa or MasterCard. If you wish to do so, please provide the following information:
a. Name of card: ___ Visa ____
MasterCard
i. Application Fee ($100)
$100______
ii. Off-campus housing deposit (see I.d. above)
___________
iii. Homestay application fee ($100)
___________
iv. Express mail ($50)
___________
v. Total amount to be charged to your credit card:
US$ ___________
b. Card number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
c. Expiration date _ _/_ _
d. Amount to be charged: $US_____
e. Name of cardholder: ____________________________
f. Signature of cardholder: __________________ Date: _______
EMERGENCY CONTACT
19. __________________________ __________________________
Name
Telephone
_____________________________________________________
Full Address
I understand the terms of my admission and agree to follow the rules of the Center and the University. I, and/or my sponsor, will be fully responsible for the cost of my studies while I am at INTERLINK. Further, I authorize the release of my credentials and of my medical records for medical and insurance purposes; I also authorize treatment of any illness or injury by qualified health personnel.
_______________________________ _____________
Signature of student or sponsor
Date