Online Application

*1. Name (as shown on Passport):

           Family                     First                  Middle

      
*2. Date of Birth:   month/day/year
*3. Country of Birth:  
*4. Home Address:  
*City  
*Country  
*5. Telephone Number:  
*5a. E-mail Address:  
*6. Emergency Contact Name:          Family                     First                  Middle
        
*7. Relation to Student:   Telephone:
*8. Address:  
*City  
*Country  
*9. When do you plan to start studying?   month/day/year
*10. Do you need the Form I-20?
*11. I will apply for my F1 Visa at an US Embassy located in the City of:  
12. SEVIS I-901 fee is included?
13. Do you want A.E.A to file the SEVIS I-901 for you?

14. Do you need medical insurance?

15. Do you need an airport pick up?
16. How did you learn of our school?
17. I want to study for
18. I want to stay in a/an
 
I want accommodations from month/day/year to month/day/year
Host Family 1: Private bedroom only
Host Family 2: Private bedroom with 2 daily meals
Apartment: Private bedroom
Apartment: Shared bedroom w/1 student (Shared kitchen and living room) 
Motel/Hotel: Approximately $60.00 to $100 per day
Do you like cats and dogs?
Do you smoke?
Do you drink alcoholic beverages?
Do you have allergies or other conditions?
If yes, please describe.


Tuition: Intensive English Program (30 hours per week)

  4 Weeks = $   545

8 Weeks = $1,075

12 Weeks = $1,575

16 Weeks = $1,995

24 Weeks = $2,500

32 Weeks = $3,150

40 Weeks = $3,650

48 Weeks = $4,200

Tuition: Semi-Intensive English Program (20 hours per week)

  4 Weeks = $   375

  8 Weeks = $   660

12 Weeks = $   875

16 Weeks = $ 1,150

24 Weeks = $1,550

32 Weeks = $1,890

40 Weeks = $2,270

 48 Weeks = $2,600

International Student Medical Insurance
1 Month =  $  68 5 Months = $340  9 Months = $612
2 Months = $136 6 Months = $408 10 Months = $680
3 Months = $204 7 Months = $476 11 Months = $748
4 Months = $272 8 Months = $544 12 Months = $816

I will pay by
1.International Money Order:
2.Credit Card:

Card Number:

Expiration Day: month/day/year
3. I will send in my payment on: month/day/year

By submitting this Online Application, I attest that I have read, understood and accept the American English Academy application process and refund policy. I also understand that while I am in the United States, the American English Academy is not liable for any of my medical expenses; that I am responsible for supporting myself; and that the information provided on my Online Application is true, correct and accurate.