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Student Application Form 2010

 NOTE
All the fields with an asterisk 
(*) must be completed

1.General information
NAME (Family) * First name * Middle name
 
Home Country Address *
 
Home Country Telephone Home Country Fax E-mail *
 
United States
Address
 
Telephone Fax Contact name
 
Birth Date Sex * Marital Status 
Month * Day * Year * Male Single
Female Married
 
Country of Birth* Country of Citizenship*
 
 

2.Course information
 
I will begin studying at Language Pacifica on (specific date) * Month Day Year
 
I will study at Language Pacifica for a duration of (1 to 32) * weeks.
I will study *
 
3. I-20 Application
 

Student visa (F-1) applicants must complete sections 1,2, and 3 for issuance of the I-20.

I need the student visa (F-1) and require 
the I-20 form 
Note: Students must be enrolled in 25 or 30 units in order to receive the I-20*

 Yes: No:

I will enter from 

If already residing in the U.S., what visa type do you currently hold?

What is your admission number ?

If on an F-1 visa, what school issued your most recent I-20? (School Name)

School fax number

Language Pacifica estimates that a student needs approximately $2000 per month in order to live and study in the United States.

  

I will, while in the United States, have $

 available to me, in the following account(s)

Personal funds $

Family funds $

Other funds $
   
A copy of the bank statement or other document which verifies the information you have given here must be attached.  
 

The financial information will be scanned and sent
by e-mail to esl@languagepacifica.com

The financial information will be sent
by fax to (650)321-2510
 

The financial information will be mailed or
hand-carried to the school
Language Pacifica
585 Glenwood Avenue
Menlo Park, CA 94025

   
 
4. Homestay Applicants

I will require Language Pacifica homestay service *

 Yes: No:

At the homestay I want

I smoke: I don't smoke:

I have the following allergies

My English level is

My profession is

My hobbies are

My date of arrival is

Day Year

My time of arrival

My date of departure from the homestay is

Day   Year
  
5. Airport Pickup Service

I will require your airport pickup service*

Flight Month

Day   Year

Arrival Time

Airport

Airline

Flight Number

6.Payment information
To make a payment you can make a bank wire transfer, send a money order or use your credit card. For credit card payment, we will process your payment the same day or the next working day, and will e-mail you a confirmation. I-20's will be mailed and homestay placements made only after payment of the following fees has been received:
 
 #All registration and homestay fees are non-refundable.
Payment options: *
Bank wire transfer information: Contact Language Pacifica office for bank details
Money Order; mail to: Language Pacifica
585 Glenwood Avenue
Menlo Park, CA 94025, USA
Credit Card VISA
MASTER CARD
AMERICAN EXPRESS:

Name as it appears on the credit card :

Credit card number :

Expiration (month/year) mm/yyyy :
Application fee # $95
Homestay placement fee # $115
Airport pickup fee # $75
Total :

 

Language Pacifica, 585 Glenwood Avenue, Menlo Park, CA 94025 T: (650) 321-1840 F: (650) 321-2510
Email: esl@languagepacifica.com