INTERLINK LANGUAGE CENTER/UNCG
APPLICATION AND RESERVATION FORM
I. How To Apply:
A. Please print this application first before you fill it out. With this application, please send by mail or fax:
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 $5000 available
c. $100.00 non-refundable application fee
d. A refundable security deposit of $100
B. Send application form and related documents and fees directly to this address:
INTERLINK
Make checks payable to "INTERLINK Language Centers".
C. If you wish to pay the above fees by credit card, please see directions at the end of this form.
II. Personal Data
1. ____________________ ________________
Family Name First Name
2. __________________________________________________
Mailing Address (PO Box or Street No.)
__________________________________________________
City/State or Province/Country
__________________________________________________
Telephone Number Fax Number
_________________________________________________
E-mail address
3. Date of birth: _______________
Day/Month/Year
4. Country of birth: _________
5. Country of citizenship:________________
6. How long do you plan to study at INTERLINK?
_________________
Estimated Number of weeks
7. When do you wish to begin your studies at
INTERLINK?
( ) January
( ) March
( ) May
( ) August
( ) October
9. After attending INTERLINK, what do you plan to do?
( ) Study for (circle one):
a. BA/BS b. MA/MS c. PhD In what field?______________
( ) Return home
( ) Travel in the
( ) Other: ______________________
10. How do you rate your English language skills:
( ) Very good
( ) Good
( ) Fair
( ) Poor
( ) None (INTERLINK has no classes for beginning level students. You should apply to a program with a beginner level.
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.):
_____ On Campus Housing
_____ Private Dorm
_____ Apartment
13. Please check below the appropriate sections which apply to you:
A. ( )Male ( )Female
B. ( )Single ( )Married
C. ( )Smoker ( )Non-smoker
D. ( ) Drinker ( ) Non-drinker
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. You and your doctor will need to fill out a student health form. Please download and print the form found at http://studenthealth.uncg.edu/forms/
15. Do you have any physical disability or health problems that will require special assistance?
( )Yes ( )No If yes, please explain:
__________________________________________________
16. Who will finance your education in the
( ) Self ( ) Family ( ) Government
( ) Other (Please specify): _______________
17. Please indicate the type of visa you will have:
( ) Student (F-l) ( ) Exchange Visitor (J-l)
( ) Other (Please specify): _______________
18. 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.
19. You may pay for your application fee, security deposit, tuition, and home stay fee by Visa or MasterCard. All other fees must be paid by check, traveler’s checks, bank draft, or cash.
If you wish to use a credit card, please provide the following information:
a. Name of card: ___ Visa ____ MasterCard
b. Card number ---- ---- ---- ----
c. Expiration date --/-- d. Amount to be charged: $US_____
¯ Application fee ($100) ¯ Security deposit ($100)
¯ Express mail fee ($50)
d. Name of cardholder: ____________________________
e. Signature of cardholder: __________________ Date: _______
Please note that there is a $25 fee if the credit card is declined by the credit
card company when we submit for payment.
EMERGENCY CONTACT
20. ______________________ ______________________
Name Telephone
_____________________________________________________
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