Marywood University: IEP Application

Application for Marywood's Intensive English Program

General Information:

Family Name: *
First Name: *
Middle Name:
Suffix:
Gender: *	Male Female
Date of birth: *
Country of birth: *
Country of citizenship: *

Mailing Address:

Address Line 1: *
Address Line 2: *
City: *
State/Province: *
Postal Code: *
Country: *

Contact Information:

Telephone Number: *
Fax number:
E-Mail Address:

Education Level:

High School: *
School Address: *
City: *
State/Province: *
Postal Code: *
Country: *
College:

Applying for: Fall (Aug.) Spring (Jan.) Summer (July)
(Application deadlines: Fall -- July 1; Spring -- Dec. 1; Summer -- June 1).

How did you discover Marywood University? (check all that apply)

Friend Brochure Web Agent Other

Have you ever taken the TOEFL test? No Yes - Score:

Have you ever studied English before? No Yes - How many Years?

Do you have Health Care? * No Yes

Will you live off campus? * No Yes

Emergency Contact Information:

Family Name: *
First Name: *
Middle Name:
Relationship: *
Telephone number: *
Fax number:
E-Mail Address: *

* = Required field.

Visa Information: If you need a student (F-1) visa, you must also complete the Certification of Finances form.

For Print Submissions:

Medical Statement: "I give permission for medical examination and treatment, authorize release of necessary health and medical information, and take responsibility for medical expenses not covered by health insurance."

Signature of Applicant: (Parent or guardian, if applicant is under 18)

_______________________________________________ Date: ____________________

Signature of Applicant: "I certify that the information on this form is true, correct, and complete. I understand that any misrepresentation may be cause for refusing or revoking admission."

Signature of Applicant:
_______________________________________________ Date: ____________________

Signature of Parent or Guardian: (if applicant is under 18)
_______________________________________________ Date: ____________________

Please return this completed form, and $500 to:

Intensive English Program
Marywood University
2300 Adams Avenue
Emmanuel Hall, Room 102
Scranton, PA 18509 USA

Method of Payment: (check one)

(   )Credit Card: ____ Master Card ____ Visa Card ____ Discover Card
         Card # _______________________________ Expiration Date ________
         Name on credit card:_______________________________________________
         Address of credit card holder:
         Addr 1: _______________________________
         Addr 2: _______________________________
         City/State/Postal: _______________________________

( )Check enclosed (payable to "Marywood University")

( )Wire transfer (attach copy)

Intensive English Program
Marywood University
2300 Adams Avenue
Emmanuel Hall, Room 102
Scranton, PA 18509-1598 U.S.A.

For more information:
  Call: (570) 340-6077 or 1-GO-MARYWOOD (1-866-279-9663)
  Fax: (570) 961-4776
  E-mail: iep@marywood.edu

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