READ AND COMPLETE BOTH SIDES OF THIS FORM

A.  Application for 20_____
          (Please write the term and the check [] the program you would like to study.)


Term                                                                       Program

         Fall (Sept – Dec) 20______                             Intensive program (day classes/full-time) _____   (day classes/part-time) _____

         Spring (Jan – Apr) 20_____                            Evening course (evening/part-time only) _____

Summer (May – Aug) 20_____                        Professional and Academic English Program (June-July only) _____

                                                                                          English for Undergraduates Program (June-August only) _____

                                                                                          Other program (please specify) _____________________________________________

        

B.  Personal Information

 

Name _____________________________________________________________________________________________________

                             family name                                                                    first name                                                                            middle name

        

 

         Sex:                        Male____ Female____                                         Birthday _______/_______/_______
                                                                                                                                                                                                                         month             day               year

         

Country of Birth ____________________________________               Native Language _________________________________________

 

Country of Citizenship _______________________________

         

 


Address in Home Country
(complete home address is required for I-20):


Street Address ______________________________________

City ______________________________________________
Province/Territory ___________________________________

Postal Code________________________________________

Country ___________________________________________

Telephone _________________________________________

Cell Phone _________________________________________

E-mail ____________________________________________


 
Address in U.S. or other country, if applicable:

 

Street Address ______________________________________

City ______________________________________________
Province/Territory ___________________________________

Postal Code________________________________________

Country ___________________________________________

Telephone _________________________________________

Cell Phone _________________________________________

E-mail ____________________________________________


Where should we send correspondence and I-20 documents?         ___ home country address OR        _____ U.S. address

PLEASE INCLUDE A COPY OF THE FIRST PAGE OF YOUR PASSPORT.

 

 


 

C.   Academic Information
          The English Language Institute (ELI) requires proof of academic preparedness for our programs.

 

Please check [] the document(s) included:

Intensive English Program (13 weeks):        

_____ proof of high school graduation OR  

_____ proof of attendance at a college or university

Professional and Academic English Program (PAEP):

_____ proof of acceptance to a US graduate program OR

_____ proof of high school graduation AND proof of a TOEFL iBT score of 80 (IELTS of 6.5) or higher

English for Undergraduates (E4U): 

_____ proof of acceptance at a US college or university OR

_____ proof of high school graduation AND proof of a TOEFL iBT score of 60 (IELTS of 6) or higher

 

High school ________________________________________________________________________________________________

                                       name                                                                                                  city/country                                                                                      year completed

 

College/university ___________________________________________________________________________________________

                                        name                                                                                       city/country                                                                                        year/degree

 

 

D.  Visa Information




If you are in the United States now:

What kind of visa do you have?

____ student (F-1)

____ visitor (B-1/B-2)

____ exchange visitor (J-1/J-2)

____ work (L or H)

____ resident

____ other (what kind?) ________________

If you are outside the United States:

What visa will you use to enter the United States? 

____ student (F-1)

____ visitor (B-1/B-2)

____ exchange visitor (J-1/J-2)

____ work (L or H)

____ other (what kind?) ________________


 

E.  I-20 Application for an F-1 Student Visa

IF YOU DO NOT NEED AN I-20, PLEASE SKIP TO SECTION F BELOW.

 

1a.  I will need a student (F-1) transfer from another school in the United States          Yes _____      No _____

1b.  I will need an I-20 from the ELI for a student (F-1) visa.                               Yes _____      No _____

1c.  I will need an I-20 form for dependents (spouse and/or children)                Yes _____      No _____

 

 

 

If you need a form for dependents, please provide the following information (continue on a separate sheet of paper if necessary):
 

 Name                        Date of birth                         Country of birth              Country of citizenship               Sex       Relationship
     _________________  ________________  ____________   ___________________  ______   __________ 

     _________________  ________________  ____________   ___________________  ______   __________ 

     _________________  ________________  ____________   ___________________  ______   __________

 

 PLEASE INCLUDE A COPY OF THE FIRST PAGE OF THE PASSPORT OF EACH DEPENDENT.

 

2.   If you need a student visa (F-1), you must complete both sections (2a) and (2b) below.

2a.             How will you pay for your tuition and personal expenses? (please check [] one)

____ Personal funds

____ My family in my home country (Provide name and address below.)

____ Family or person in the United States (Provide name and address below)

____ Scholarship from sponsor organization (Provide name and address below.)

         Name of sponsor _______________________________________ Relationship __________________

         Address  ___________________________________________________________________________

                       ___________________________________________________________________________

Telephone ______________________________________________________

Fax ____________________________________________________________

Email __________________________________________________________

 

2b. Financial guarantee information

YOU MUST INCLUDE A FINANCIAL GUARANTEE WITH THIS APPLICATION TO RECEIVE AN I-20.

The required bank statements must show that you have enough financial support to live for one semester.  The required figures on the bank statement are:

Š           US $9,900 available for tuition and personal expenses for intensive ELI program

Š           US $5,500 available for tuition and personal expenses for the Professional and Academic English Program

Š           Please see the ELI Admissions section of the ELI website for additional amounts required for dependents: www.eli.pitt.edu

 

What kind of financial guarantee are you providing?  (please check [] one)

 

_____ A current, original bank statement in your own or your parents’ name

_____ A current, official scholarship award letter from your sponsor organization.

           THIS SCHOLARSHIP LETTER MUST STATE THAT YOUR SPONSOR WILL PAY FOR
                     ENGLISH COURSES AND PERSONAL EXPENSES.

 

_____ A current, original bank statement from a personal sponsor in the United States AND a letter
                     from your sponsor stating that the sponsor will be responsible for your tuition and personal
                     expenses.

 

 

F. How did you first learn about the ELI?

___ ELI web site (www.eli.pitt.edu)

___ current or former ELI student (name: ____________________________________________________)

___ government or scholarship agency (name: ________________________________________________)

___ at a recruitment or education fair or expo (name: ___________________________________________)

___ an ESL or study abroad web site (web site address: ________________________________________)

___ a recruitment or study/travel abroad agent (name: __________________________________________)

___ school counselor or school study abroad office (name: ______________________________________)

___ other (explain: ______________________________________________________________________)

                         

 

G. Before signing this application form, please read and check [] all
     the statements below.

___ I understand that there is no beginning-level course at the ELI.

___ I understand that I must have enough money to pay my tuition, university fees, and personal expenses while I am in the United States.

___ I understand that I must provide proof of my health insurance policy to the ELI for the intensive English Program (starting Fall 2016).

I have included:

___ a copy of the first page of my passport

___ a copy of the first page of each of my dependent’s passports (if needed)

___ proof of academic preparedness:

 __ Intensive English Program (13 weeks):  proof of high school graduation or attendance at a college/university

 __ Professional and Academic English Program (PAEP) or English for Undergraduates Program (6 weeks): proof of university acceptance or TOEFL/IELTS requirement

___ financial guarantee information to obtain an I-20 (if needed)

___ a letter from my personal sponsor in the US stating that the sponsor will be responsible for my tuition and
       living expenses (if needed)

     I have included all necessary fees and payments made payable to the University of Pittsburgh.

___ Non-refundable deposit:

      __ $300 non-refundable deposit toward Intensive English Program tuition (required) OR

      __ $500 non-refundable deposit toward Professional and Academic English Program tuition (required) OR

      __ $500 non-refundable deposit toward English for Undergraduates Program tuition (required)                        

___ $75 nonrefundable application fee (required)
___ $70 for express mail (if needed

$________________________ total amount enclosed

 

CHECK MUST BE IN U.S. DOLLARS OR DRAWN ON A U.S. BANK and MADE PAYABLE TO “UNIVERSITY OF PITTSBURGH”

     

Signature of applicant ___________________________________________  Date _____________________
                                                                                                                                                    month/day/year

 

H.  Mail application form

Please be sure to provide all required information, and sign and date this application form. Then, send by postal or express mail the completed application form, academic information documents, financial documents (if needed), deposit, and application fees to:

 


University of Pittsburgh

English Language Institute

Attn: Admissions Officer

Parkvale Buildling, Room M13

200 Meyran Avenue

Pittsburgh, PA 15260 USA


Telephone:  412-624-5901

Fax:  412-624-6130
E-mail:  elipitt@pitt.edu

www.eli.pitt.edu