International Students Dispatch Application

Personal Information

First Name:(Required)

Last Name:(Required)

Middle Name(Required)

Preferred Name(Required)

Sex(Required)

Date of birth(Required)

PHONE TYPE

Mobile

Landline

Other

Phone Number 1(Required)

Phone Number 2

Email Address(Required)

Product Name

HOME ADDRESS

Home Country

IS YOUR HOME ADDRESS DIFFERENT THAN YOUR CURRENT MAILING ADDRESS?

Yes

Address 1

Address 2

City

State

Zip

CITIZENSHIP

Country of Citizenship

Country of birth

Address Line 1

ARE YOU PROFICIENT IN A LANGUAGE OTHER THAN ENGLISH?

Yes (Please List) :

Other Languges

RACE/ETHNICITY

International

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Hispanic

CURRENT U.S. VISA TYPE, IF ANY

ACADEMIC HISTORY

HIGH SCHOOL NAME

From

HAVE YOU TAKEN ANY COLLEGE/UNIVERSITY COURSES?

Yes (Please List):

COLLEGE/UNIVERSITY NAME

From

Are you currently residing in the United States?

Yes

If no, where are you residing currently?(Required)

Start Date

Fall

Winter

Spring

Summer

How did you find us?

APPLICATION FEE AND ACCEPTANCE OF TERMS

A non-refundable application fee must accompany this completed application. Please have transcripts from any schools listed on this application form forwarded to us a soon as possible. I grant Academy College permission to provide to a third party or parties any or all of the information which is contained in the school’s student or graduate files and records of myself, and information which is usual and normal in the conduct of business of a school. Notwithstanding anything to the contrary, all tuition, fees, and other charges paid shall be refunded to students if written notice of cancellation is given within five (5) business days after the day on which the student application is accepted by the school, regardless of whether or not the program has started.

Application Fee: $40.00

School Catalog Received:

Initials

SIGNATURE OF STUDENT:

Date

My signature above indicates that I understand that the school catalog is the complete statement of all terms and conditions of my contract with Academy College. This agreement becomes a legally binding instrument upon written acceptance of the stu- dent by Academy College unless canceled pursuant to the Refund Policy as stated in the school catalog.

EMERGENCY CONTACT INFORMATION

Last Name:

First Name:

Phone

RELATIONSHIP

Application Fee: $40.00

I have enclosed(Required)

I have enclosed $40 for my application fee

Payment Method(Required)

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name