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ENGLISH LANGUAGE PROGRAM REQUIREMENTS
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STUDENT'S NAME: ____________________________________ DATE OF BIRTH: _________________
ADDRESS: ____________________________________________________________________________
TELEPHONE: ________________________ FAX: _______________________
E.MAIL ADDRESS: _________________________________________________
SCHOOL ATTENDING/ED: _______________________________________________________________
DIPLOMA RECEIVED: _____________________________________________ YEAR: _______________
LANGUAGE OF INSTRUCTION: ___________________________________________________________
FIRST LANGUAGE: ___________________________________ YEARS OF ENGLISH STUDY: _________
DATES AVAILABLE: ______________________________________
LOCATION PREFERRED: __________________________________
PREFERRED LIVING: COLLEGE/UNIVERSITY CAMPUS: _______________
APARTMENT: ______________ FAMILY:______________
OTHER REQUIREMENTS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please fax this completed form to 203-966-3832. Upon receipt of the questionnaire and the Contract for
Services, we will recommend programs for your consideration.
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