Request a free price quote before you register.

A. PERSONAL INFORMATION

Email Address:

Family Name:    

First Name:       

Middle Name:   

Birth Date (Month/Day/Year):

Male   Female

Have you studied at ICC before?   Yes

Country of Citizenship: 

Country of Birth:          

City of Birth:                

Hours per week of study:  

View the ICC class schedule.

16hrs/week (Semi-Intensive Course--no student visa)
20hrs/week (Intensive Course--student visa required)
25hrs/week (Super-Intensive Course--student visa required)

Type of visa you will study on:

F-1 Student Visa Information

Visa Waiver B2 Visitor Visa F1 Student Visa I am a US Citizen I am a Permanent Resident Other

 If you have selected Permanent Resident, enter your Alien Registration Number

If you have selected other, please enter the type:

Are you transferring from another school?  Yes

If you are transferring from another school, what is the last day of study there: (Month/Day/Year)

If you are transferring from another school, what is that school's name?

Are you registering through an authorized ICC agency?   Yes

If you are registering through an authorized ICC agency, name of agency?

Name of agency counselor?

How did you hear about ICC?

B. HOME COUNTRY ADDRESS

Street Address:

City or town: 

State or Province or Prefecture

Country:

Zip Code/ Postal Code

Telephone (Include country and area codes)

Fax Number:

C. NEXT OF KIN/EMERGENCY CONTACT PERSON

First Name:

Family Name:

Relationship:

Complete Address:

Home Phone: Work/Cell Phone:

Email Address:

D. STUDYING AT ICC

Registration Start Date:    Registration End Date:

Length of study (number of weeks):

View our term calendar for start dates.

Extended Stay Program (ESP): one year program with 36 weeks of study divided into
three 12 week study sessions and two 8 week vacations.
    ESP Option
      ESP - One Time Payment
      ESP - Semester Payment (Three Payments)

Program of Study:

English For Communications (EC) English for Business (EB) TOEFL/University Preparation University Bridge Program Cambridge Program (FCE, CAE) Cambridge Intensive Program (FCE) CELTA Teacher Training Course Private Lessons Computer Assisted Language Learning (CALL)

Current Level of English:

Beginner Intermediate Upper Intermediate Advanced Fluent

E. AIRPORT TRANSPORT

Arrival: Do you need airport pickup on arrival? Yes       No: 

If yes please enter Airline:

Flight Number:

Date of arrival:

Time of arrival:

City in which flight originates (e.g. New York, Los Angeles, Tokyo):

Departure:   Do you need airport drop-off on departure? Yes       No: 

If yes please enter Flight Number:

Airline:

Date of departure:

Time of departure:

Origin of flight:

F. ACCOMMODATIONS: Please provide a first and second choice of accommodation in case your first choice is unavailable.

Accommodation start date:  

Accommodation finish date:

First Choice of accommodation:

No accommodations Homestay Hotel or studio apartment Dormitory Apartment

Second Choice of accommodation:

No second choice Homestay Hotel or studio apartment Dormitory Apartment

Do you smoke?   Yes (If yes, you must smoke outside only)

Do you have allergies?   Yes If yes, please describe.

Do you take any medications?   Yes If yes, please explain.

Do you have any hobbies or particular interests?  Yes If yes please describe.

Can you live with pets?   Yes     Cats Only:    Dogs Only:    No

Can you live in a family with children?   Yes, any age     Yes, but not under 5 years old      No

Do you have any religious beliefs requiring certain foods (diet) or other special needs?
      If yes, please explain.

G. PAYMENT INFORMATION:

How will you pay?

Credit card Wire transfer Bank draft-certified check Other

If you plan to use a credit card, what type will you use:

Visa Mastercard American Express JCB

If other describe:

Please include with your application:

a. $400 deposit that goes toward payment of tuition and school fees

b. For F-1 Students, a Bank Statement in English (original; current within 2 months of application date) to show you proof that you have sufficient funds to stay in the USA. The financial statement must include your name or your parent's name, account number, account balance (minimum $2,000US per term), signature of bank official, and date of statement.

c. For F-1 Students, a Letter of Financial Support if you are supported by your parents or other persons.

d. Would you like us to express mail your I-20 for delivery within 7 days?  (This requires an additional fee of $50-$100.)
Yes No

e. Would you like us to make your $200 SEVIS payment to the Department of Homeland Security? (The I-901 SEVIS fee will be charged to your credit card. You can also make the payment yourself at www.fmjfee.com. More information about the fee can be found at http://www.ice.gov/sevis/i901/index.htm).
Yes No

If paying with a credit card (VISA, Mastercard, American Express only), please print out and fax or mail this Authorization Form. to ICC with your credit card number.

If paying with a credit card, what is the name on the Credit Card:

If paying with a check, make checks payable to: ICC-Hawaii

If paying with a wire transfer please contact us for bank transfer information.

H. CONDITIONS OF ENROLLMENT AND REFUND POLICY

I agree that I will purchase medical insurance prior to starting any ICC program and will cover all medical expenses
or reimbursements during my study program:  Yes

I have read and agree to be bound by the Refund and Cancellation Policy    Yes

I confirm that my deposit of $400US (toward payment of tuition and school fees) will be made to confirm my registration    Yes

I. STUDENT AGREEMENT

I certify that the information provided on this application form is correct. I fully understand that persons coming to the US on a student visa are expected to study full-time. I understand that if I decide not to attend ICC, I must return my I-20 form (if full-time) to the school to get a full refund. I have read and understand the information in this enrollment agreement, and the ICC cancellation and refund policy.   By signing this agreement, I authorize ICC to credit my account if the deposit is greater than my initial tuition and fees. I understand that ICC has the right to change policies, prices and programs without prior warning. All information on this form is true and accurate to the best of my knowledge. This contract is legal and binding.

Student's Name:         Date:

Guardian's Name (if under age 18):       Date:

Authorized ICC agent's name:     Date:

J. Notes

Fill out this application and then select the Submit button below. Press submit only once. If you make a mistake before submitting return to the section and change it. If you wish to erase all information and start over press the reset button.