HARVEST BOOKING FORM

Application for admission

Please, provide all requested information accurately and click on submit

Part 1 (Personal Information)

First name: A value is required.

Last name: A value is required.

Middle names:

First Language: A value is required.

City and Country of Birth: A value is required.

Country of Citizenship: A value is required.

Date of Birth: (mm/dd/yyyy) A value is required.Invalid format.

Male

Female

Passport Number: A value is required.

Expiration Date: (mm/dd/yyyy) A value is required.Invalid format.

Address:

Street: A value is required.

City: A value is required.

State: A value is required.

Zip Code: A value is required.

Telephone: A value is required.

E-mail: A value is required.Invalid format.

Emergency Contact: A value is required.

Phone: A value is required.

Relationship to Student: A value is required.

Part 2 (Hobbies and other interests) “This information is optional”

What are your career or study plans?

What are some of your hobbies?

What are you looking to achieve by coming to the USA?

Part 3 (Academic Information)

What do you estimate your level of English to be?

Beginner

Intermediate

Advanced

What are your areas of interest? Check all that apply:

Grammar

Conversation

Pronunciation

Creative Writing

TOEFL

TESOL

How many hours do you want to study per week?

Other:

Start Date: (mm/dd/yyyy) A value is required.Invalid format.

For how long? A value is required.Invalid format.

Months

Weeks

Part 4 (Financial/Sponsor)

Are you paying for your trip and study expenses or do you have a sponsor?

Self

Sponsor

**If sponsored please have your sponsor fill out the following information:

Full Name: (First/Middle/Last)

Full Address:

Relationship to student:

Phone number:

E-mail Address: Invalid format.

Part 5 - Payment Information

I am paying:

$200.00 Registration and processing

$100.00 for the I-901 and a $25.00 fee for this service

$25.00 Express Mail (there is no additional fee for regular post office delivery, but documents may take much longer to arrive)

Indicate form of payment:

Check (Drawn in US bank)

Credit Card

Money wire Transfer

Bank Wire Transfer to: Harvest English Institute - Independence Community Bank – 900 Springfield Rd. Union, NJ 07083 – Phone: (908) 206-8818 - Account number: 1340001625 - Routing number: 231372691 with no charge to beneficiary, Harvest English Institute

Part 6 - Agency Information

If you are being represented by an agency this is for their use only:

Agent:

Agency:

Country:

Phone:

Fax:

E-mail: Invalid format.