FOR ELI USE ONLY: DATE ______________ INITIALS _______ ID NUMBER __________________

THE UNIVERSITY OF TEXAS-PAN AMERICAN
ENGLISH LANGUAGE INSTITUTE
Admission Application
Intensive Program

1201 W. University Drive/Bldg. E
Edinburg, TX   78541-2999

Telephone: (956)381-2133      Fax: (956)384-5001
Email: eli@utpa.edu     Website: http://www.utpa.edu/eli


  • I am applying for:  [ ] Fall I   [ ] Fall II [ ] Spring I [ ] Spring II [ ] Summer I [ ] Summer II -- of 20____
  • Have you studied in the English Language Institute before? [ ] No [ ] Yes.  If Yes, When_______?
    Where?   [ ] Edinburg     [ ] Hidalgo
  • What is your level of education?
    [ ] Have not finished High School [ ] Completed High School or equivalent [ ] University
  • How did you find out about the English Language Institute (ELI)?
    [ ] Friend or relative [ ] Website [ ] Flyer [ ] Other ____________________________
  • Are you a legal resident or citizen of the US? [ ] Yes [ ] No.
    (You need an I-20 form for an F-1 student visa to study if you are not a legal resident or citizen of the US.)
  • Do you need an I-20 for an F-1 visa? [ ] Yes [ ] No


Please print clearly.
[ ] Female               [ ] Male                                                                                UTPA ID#:_________________________

Name: _____________________________________________________________________________________
                 Last Name (Name as it appears on passport)              First Name                                 Middle Name
Country of Birth      Country of Citizenship      Date of Birth: ______    ______    ________
______________      _________________                                   (month)          (day)            (year)


Permanent Address in your home country:

____________________________________
Street Address

____________________________________
  City         State     Postal Code     Country

Current Address in USA:

____________________________________
Street Address

____________________________________
  City         State     Postal Code     Country


Email Address: _____________________________                    Telephone: ___________________ (Permanent)        
                                                                                                                                 ___________________ (Local)

Are you now in the United States on an F-1 student visa?    [ ] yes     [ ] no
    If yes, write the name of the institution that issued your I-20? __________________________
(You need to apply for an I-20 from the English Language Institute in order to transfer your student status.)
If you are not on an F-1 visa, what type of visa do you currently hold? __________________

 

 

 

Do you, as an F-1 student, have dependents (spouse and/or children) requesting entry?
[ ] Yes, list all you dependents      [ ] No
Last Name First NameDate of Birth (Month/Day/Year) Country of Birth Relationship to Student
         
         
         
         

In accordance with provisions of Section 504 of Rehabilitation Act of 1973, the University requests information on disabilities solely for the purpose of offering appropriate accommodations to disabled students. Your response on this form is voluntary and will be kept confidential. Failure to provide the information will not subject you to any adverse treatment.

(Optional) Do you have a physical, sensory or mental disability, or medical condition that substantially limits one or more of life activities (e.g. walking, seeing, hearing, breathing, learning)?
[ ] No       [ ] Yes (If yes, describe _________________________________________)

Student Agreement
I have carefully read this form and completed it personally. I certify that all the information on this application form is true and correct to the best of my knowledge. Giving false information may make me ineligible for admission to this program.

  • Refunds will be given only before the starting date of the program. Refunds require 4-6 weeks to process. Only applicants who cannot be placed in existing levels will be given a full refund.
  • I cannot be transferred to another session, unless I get prior approval from the Director and there will be a $50.00 charge.
  • I understand that a $100.00 processing fee and any late fees are non-refundable.
  • I was advised about the requirements needed before an I-20 Form can be issued, for example, a bank statement.
  • I was offered assistance with the I-901 Form and on how to pay for the SEVIS fee, which is required before making an appointment with the American Consulate.
  • [ ] I will pick up my I-20 Form.                I want my I-20 Form mailed to my:   [ ] Permanent address    [ ] Current address.
  • I was issued a testing date. ________________
  • I understand there will be no level changes
  • I have enrolled in the correct session
  • I was told where to obtain a Parking Permit.
  • I was issued a UTPA ID Number.
  • [ ] I am not a minor (18 or older).     [ ] I am a minor (17 or younger) and have filled out the Minor and Medical Release Form.
  • I have Medical Insurance that is valid in the USA?   Yes     No     Exempt
_________________________________         _______________
Applicant's Signature                                            Date