TAMPA LANGUAGE CENTER
9309 N. FLORIDA AVE. SUITE 109 TAMPA, FL 33612
PH (813)988-7900 FAX (813)980-3751
[email protected]
Application Form/F-1 Students (General English Program)*Required Fields
Reason for I-20:
Initial Attendance
Initial Attendance (Change of Status)
PART 1. Applicant Information
Last Name(s)*:Last Name(s)
First Name(s)*: First Name(s) and Middle Initial
Sex*:Choose One
Date of Birth*: M 00/D00/ Y1988
City of Birth*: Country's Name
Country of Birth*: Country's Name
Country of Citizenship*: Country of Citizenship
Native Language*:Language
Preferred communication*: Choose One
Email Address*: [email protected]
U.S. Emergency Contact*: Name
U.S. Emergency Contact Number*: (000)000-0000
US Phone Number*: (000)000-0000Second Number: (000)000-0000
U.S. Address*: 1234 Green St.
APT#: 101
City*: City
State*:State
Zip Code*:00000
Foreign Telephone Number*: 1+00-0000-00
Foreign Address*: 1234 Green St.
City*: City
State/Province/Territory*: State
Postal Code*: 00000
Country*: Country
Transfer In
PART 2 A: Program Information
Start Date*:M 00/D00/ Y1988
Course Duration:
Start Quarter:
End Date*:M00/D00/Y1988
3 months
6 months
9 months
12 months
Quarter 1 (Jan, Feb, Mar)
Quarter 2 (Apr, May, Jun)
Quarter 3 (Jul, Aug, Sep)
Quarter 4 (Oct, Nov, Dec)
Course Costs:*This portion to be filled out by TLC staff*
A. $__________________ Application Fee ($100) (Non-Refundable)
B. $__________________ Registration Fee ($150/180) (Non-Refundable)
C. $__________________Postage/Courier fee (Varies by Country) (Non-Refundable)
D. $__________________Total Tuition($2995/quarter or $1040/monthly) (See Terms and conditions for refund policies)
F. $__________________Placement test($25)
Students have the option to pay every quarter in advance ($2,995.00 per quarter) or in monthly installments ($1,040.00/month), plus $25.00
placement test and $150.00 or $180.00(with TOEFL or IELTS training) for registration at the beginning of their first enrolled quarter.
**Total funding must cover all tuition, student fees, and living expenses as calculated(typically $6000/single student). Formal proof of availability of funds
(e.g., bank certification of funds on bank letterhead) is a requirement of the I-20 application process.
PART 3: Mandatory Government Fees (May be paid directly to U.S. Department of Homeland Security)
A.
For a first-time applicant (Initial Attendance):
$200.00 I-901 (SEVIS FEE)
B.
For an applicant, currently in the U.S. on a tourist or other type of
$200.00 I-901 (SEVIS FEE) AND
visa who wishes to apply for a change of status
$370.00 I-539 Processing Fee
For an applicant transferring from another school with an I-20
No Government Fees Apply
C.
PART 4: Disclosure Acknowledgment
I am applying for an I-20 (Certificate of Eligibility for Nonimmigrant {F-1} Student Status) and the reason for my application for a student visa, change of
status to F1, or transfer on my SEVIS record is to improve my English language skills at Tampa Language Center. I fully understand the terms and
conditions as described to me in the Terms and Conditions of Admission provided by Tampa Language Center, including the course study requirements,
refund policies, and U.S. immigration reporting requirements. I am aware that once my visa, change of status, or transfer is approved, information
concerning my enrollment will be reported regularly to the U.S. Department of Homeland Security, as required by law.
Withdrawal after attendance has begun is based on the following refund policy for all programs of two hundred forty (240) instructional hours or more:
If Withdrawal or Cancellation occurs:
During 1st Week
During 2nd Week
During 3rd Week
During 4th Week
After 4th week
0% of tuition
The School Will Refund
90% of tuition
80% of tuition
60% of tuition
40% of tuition
I, the undersigned, understand the refund policy in its entirety. As a student at Tampa Language Center, I will follow the institute's withdrawal policy
concerning tuition fees.
________________________________
___________________________________
________________
Student's or Guardian’s Name Printed
Student's or Guardian’s Signature
Date
This document must be printed, signed, and scanned in order to be valid. Email to :
[email protected]
PART 5: Dependent Information (If Necessary)
Dependent Last Name(s)*: Last Name(s)
Dependent First Name(s)*: First Name(s) and Middle Initial
Sex*:Choose One
Date of Birth*: M 00/D00/ Y1988
Country of Birth*: Country's Name
Country of Citizenship*: Country of Citizenship
Relationship*:Choose an item.
Remarks: Additional Remarks
Dependent Last Name(s)*: Last Name(s)
Dependent First Name(s)*: First Name(s) and Middle Initial
Sex*:Choose One
Date of Birth*: M 00/D00/ Y1988
Country of Birth*: Country's Name
Country of Citizenship*: Country of Citizenship
Relationship*:Choose an item.
Remarks: Additional Remarks
Dependent Last Name(s)*: Last Name(s)
Dependent First Name(s)*: First Name(s) and Middle Initial
Sex*:Choose One
Date of Birth*: M 00/D00/ Y1988
Country of Birth*: Country's Name
Country of Citizenship*: Country of Citizenship
Relationship*:Choose an item.
Remarks: Additional Remarks
Dependent Last Name(s)*: Last Name(s)
Dependent First Name(s)*: First Name(s) and Middle Initial
Sex*:Choose One
Date of Birth*: M 00/D00/ Y1988
Country of Birth*: Country's Name
Country of Citizenship*: Country of Citizenship
Relationship*:Choose an item.
Remarks: Additional Remarks