Application

Application to the English Language Center (ELC)

Return to:

Dr. Charles G. Gauvin, English Language Center, PO Box 971222 Orem, UT 84602
Phone: (801) 437-9371 Fax: (801) 422-0474

Personal Information

Name	_____________________________________	___________________________________________	___________________________________
Name	Last	First	Middle

Birthdate	_______/	________	/_______
Birthdate	Month	Day	Year

Gender:

Male

Female

Marital Status
(Please check one.)

Married
Single

United States Social Security Number (if applicable)	__________—__________—__________
	(Do not use a foreign insurance number)

Complete Mailing Address	______________________________________	__________________________________
	______________________________________	__________________________________
	______________________________________	__________________________________
	Country	Zip Code

Phone	________________________		Fax (optional)	_________________________	Email (optional)__________________
	Country Code — City Code — Number			Country Code — City Code — Number

Country of Citizenship ______________________ Country of Birth _______________________ Native Language ______________________

Parent or Guardian’s Name _______________________________	Telephone ________________________________
Name of friend, if any, in the U.S. __________________________	Telephone ________________________________

Registration Information

Indicate the year and semester(s) you plan to enroll: Year ____________

Fall & Winter September—April (Deadline–May 1)	Winter & Summer January—August (Deadline–August 1)	Summer & Fall May—December (Deadline–December 1)
Fall only September—December (Deadline–May 1)	Winter only January—April (Deadline–August 1)	Summer only May—August (Deadline–December 1)

How many years have you studied English? ______ Are you a beginning, intermediate, or advanced English Speaker? _______

Education

Please fill in the following information starting with most recent school attended. A copy of your high school and college transcript (if applicable) must also be included with your application.

Degree	Date Completed	Major	University/High School	School Address

Religion

Religious Affiliation

LDS (Mormon)

Other_______________________________

If LDS, home ward/branch ________________________________

Stake/mission______________________________________

Have you served a full-time LDS mission?

Yes

If yes, please complete the following information:

Name of Mission________________________________________	Start Date	______/______	End Date	______/______
		Month/Year		Month/Year

Essay

Please write in your native language (or English) an essay addressing the topic "Why I want to study at the English Language Center." You may type your essay with a word processor and attach it to the application. If you do, please make sure your name is written on the upper left-hand corner. Please limit your essay to no more than 300 words.

Family Information

If a spouse and/or any children will be accompanying you, please complete this portion of the application. If you will be coming by yourself, please go to the next section. Please note: An additional $700 per dependent, per semester must also be proven on a bank statement in addition to the funds which must be proven for the student ($4,325 for one semester or $8,650 for two semesters).

Family Name	Given Name	Bir	th Date		Country of Birth	Relationship to Applicant
1. ___________________	______________________	_______/	_______/	_______	________________	_________________
		Month	Day	Year
2. ___________________	______________________	_______/	_______/	_______	_________________	_________________
		Month	Day	Year
3. ___________________	______________________	_______/	_______/	_______	_________________	_________________
		Month	Day	Year
4. ___________________	_____________________	_______/	_______/	_______	_________________	_________________
		Month	Day	Year

If necessary, please list additional dependents on a separate sheet of paper.

Special Accommodations

If you have a physical or emotional disability which will require reasonable accommodations, please attach a letter describing the nature of the disability and list what accommodations will be needed. Special accommodations for functional limitations must be preapproved.

Payment

Enclosed is my payment in the amount of $_______________

Application fee (non-refundable)
Tuition (one semester)
Express mail fee (optional)

$150
$2,800
$50

_______________________________	____________________
Total	$2,950 or $3000

_________________________________________	_____________________________________________________	_______________
Signature of Applicant	Signature of Parent or Guardian if applicant is under 18 years of age	Date