ESL Application for Admission

ESL Application for Admission
I wish to study:*

Full-TimePart-time
What is your estimated level of English language proficiency?

Beginner: No English/Very little EnglishIntermediate: Able to communicate socially about familiar topicsHigh Intermediate: Able to communicate confidently in most social situations; can use and understand academic English with guidanceAdvanced: Able to use English fluently in all contexts, both social and academic
Personal Information

Please answer ALL questions to avoid delay in consideration for admission.
Your name as it appears on your passport*
First Name
Middle Name
Last/Family/Surname
Gender

MaleFemale
Permanent Address*

Street or PO Box

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Local Address*

Street or PO Box

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Birthplace*
City, State, Country
Guardian's Name (If applicable)

First NameFamily Name
Guardian's Address

Street/PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian's Phone Number

Area CodePhone Number
Relationship to You
Check the box that most appropriately indicates your current status*

U.S. CitizenPermanent Resident of USA (Green Card)International student with an F-1 VisaOther VISA - Please explain below
Resident Alien ID#
Provide number if applicable
Country of Origin
SEVIS Number
Please provide number
Please explain current status in the U.S.
Please indicate your ethnic origin. (This information is optional and is requested for use on federal and state reports as well as institutional research. Ethnic origin is not used to determine one's eligibility for admission.)
Are you Hispanic or Latino?

YesNo
How would you describe your racial background? Please select one or more of the following categories:

WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Religious Affiliation

CatholicOther
Health Insurance

All fulltime students must have health insurance. If you plan to be enrolled fulltime, please list the name of your insurance company and the policy number. If you do not have medical insurance, you can purchase a policy when you begin your studies.
Insurance Company
Policy Number
Academic Information

High School/Secondary Education: List the name of each high school/secondary school in order of attendance. Please submit a copy of your educational transcripts: a copy of the original and an English translation if needed. If high school/secondary school is based on an equivalency exam, submit a copy of your equivalency completion certificate and test scores.
Are you currently a high school student*

YesNo
If yes, please list name of school and academic year

Name of SchoolAcademic Year: Sr, Jr, Soph, Frosh

High School Information*

	Name of School	City/State/Country	Beginning Date	Actual or Expected Date of Graduation or completion
1
2

College/University Education (if any): List name and location of colleges or universities in order of attendance. Please submit a copy of your educational transcripts; a copy of the original and an English translation if needed.

College/University Information

	Name of College/University	City/State/Country	Beginning Date	End Date	Degree Earned	Field of Study
1
2

Emergency Information

Please list the name, address, phone number and relationship of someone the college can contact in case of emergency.
Name*

First NameFamily Name
Relationship to You*
Address

Street/PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Please read this paragraph before signing this application form.

I hereby certify that the above information is true and that, if admitted to Divine Word College, I agree to be governed by the College's regulations, policies and academic standards. By signing this application form, I authorize the Admissions Committee of Divine Word College to use this form and other admission materials to evaluate my application. Completing this application does not mean automatic acceptance to Divine Word College.
Name*

First NameMiddle NameLast/Family/Surname
Email*
example@example.com
Date*

MonthDayYear
Date
In addition to this application form, you will also need to provide:
- A letter of recommendation from your current or former teacher or supervisor
- Copies of high school and/or college transcripts (one in original language and another translated into English)
- Copies of immigration documents: Visa, Passport, I-94, I-20
- $25 non-refundable application fee
Should be Empty:

ESL Application for Admission

Personal Information

Academic Information