APPLICATION FORM
IEC Year-Round Intensive Program

Personal Information

Name (Family, first, Middle): _______________________________________________________________

Birthdate (month/day/year):  / /          Male/Female:

Country of Birth: Country of Nationality:
Are you married (Y/N)?                  Will you bring your spouse/children (Y/N)? 
If yes, please fill out the information below:

A copy of all family members' passports must accompany your application.

Are you transferring from another school in the U.S.? Yes  No  School ______________________________

Calendar - Check EACH session for which you are applying:

Spring I: January 11 - March 6, 2012
Spring II: March 7 - May 8, 2012**
Summer: June 6 - July 31, 2012
Summer II: July 2 - July 31, 2012
Fall I: August 22 - October 16, 2012
Fall II: October 17 - December 18, 2012***

Spring I: January 9 - March 5, 2013
Spring II: March 6 - May 7, 2013**

**Includes one week University Spring Break
***Includes one week Thanksgiving Break

Housing: University Housing is open to IEC students on a limited basis. Dormitory rooms, University Apartments and the Boulder Hotel are assigned as available. Check ONE box for the housing you will need:

1. University Dormitory room and board (2 students to a room.) Non-Smoking Only.

Meal Plan 19 meals a week 15 meals a week 10 meals a week


2. University Owned Apartments (private room in shared apartment.)
Non-Smoking Only.

Please Note: : A Housing Fee of $300 (U.S.) must be included with this application if you want the IEC to arrange housing for you.

We will not refund your Housing Fee unless your Student Visa is denied.

3. I do not need help with housing. I will find my own housing (hotel, apartment).

Financial Support (See Fees and Expenses below.)

A financial guarantee/statement or letter verifying availability of funds to support you during your IEC studies must be submitted with the application. This statement or letter must be written by the bank or supporting agency. Check the line below indicating financial responsibility.
Parent Guardian Self

Other (explain relationship; i.e. sister, brother, friend, etc.)
Responsible Person's Name(Please Print):

Name of Agency/Company: 
Responsible Person: 

Telephone:  Fax: 

Signature of Responsible Person who will pay the IEC tuition and fees:

Please Print ______________________________ Signature ________________________ Date _______________

Additional Information:

How did you learn about the IEC? ________________________________________________________________

(Friend or Relative? Internet? IEC Website? Agent? Magazine or Guide? Other? - Please be a sspecific as possible.)

What year did you graduate from high school?

Have you attended a university or college? Yes  No 

Do you have a pending criminal charge OR have you ever been convicted of a crime, made a plea of guilty, accepted a deferred judgement, been adjudicated, or been required to register as a sex offender? (Misdemeanor traffic offenses are exempt.) Yes  No 

Have you ever been placed on probations, suspended, expelled or been subject to official disciplinary action from any high school or postsecondary institution for any academic misconduct or behavioral misconduct? Yes  No 

I hereby certify that, to the best of my knowledge, the information furnished on this application is true and complete. I understand that if found to be otherwise, it is sufficient cause for refusal or dismissal.

Applicant Signature:___________________________________________________Date_______________

Fees to be paid at time of Application (MUST accompany Application):
 

Fees and Expenses: 

* Tuition, Student Fees and Health Insurance Costs are subject to change without advanced notice.

**Estimated costs in US$

No financial assistance is offered for study at the International English Center (IEC) of the University of Colorado at Boulder. Students must have adequate funds available for the duration of their stay. The Regents of the University of Colorado at Boulder reserve the right to change fees without notice.

Health Insurance
Health insurance is required for all IEC students. On registration day all students must either show proof of insurance or buy health insurance through the IEC.

Application Process
Please apply as early as possible to allow sufficient time for visa processing. Complete all parts of the application and attach the following:

• Copy of Passport Identification Page. (Include a copy of all family members' passports if they well be coming with you.)
• Recent passport-size photo of yourself. No photocopies.
• Financial Guarantee/Statement or letter verifying the availiability of funds (from a bank or supporting agency.)
• Application fee of $100 and express mail charges of $54.00 U.S.
• Housing Reservation fee of $300 U.S.

Please Note: Your application CANNOT be processed and no I-20 Form can be issued until all the required materials and payment have been received by the International English Center. Please keep a copy of the application form and documents for your records.

Payment Information: Fees sent with Application

$100.00 Application Fee (non-refundable)

$300.00 Housing Fee ( non-refundable, see Housing Preference.)

$54.00 Express Mail Charge

Payment Method:

I have enclosed a Money Order or a US Bank check payable to the "University of Colorado".

I choose to pay with the following credit card. (Do not send credit card info via e-mail.)

Master Card Visa Discover

Card Number: ________-_________-________-________ Expiration Date: _____/_____ Vin: ______

Cardholder's Name: ___________________________________________

Authorized Signature: __________________________________________

Amount Due from Above: US $ ___________________________________________

For Wire Transfer Information, please contact our office for instructions.

Send or fax completed application, payment, and all necessary supporting documentation to:

International English Center
University of Colorado at Boulder
1030 13th Street (63 UCB)
Boulder, Colorado 80302 U.S.A.
Telephone: (303) 492-5547 Fax: (303) 492-5515
E-mail: ieccu@colorado.edu

http://www.colorado.edu/iec/

07/2010