2010 APPLICATION AND I-20 REQUEST FORM

FOR THE SIX-WEEK INTENSIVE PROGRAM

Term name:_____________________________

Month term begins:_______________________ Year of term:_____________

Student Name (as it appears on the student's passport):

Last Name: ______________________________

First Name: __________________________ Middle Name: _____________________

Birthday: Month: ______________ Day: ____________ Year: _____________

Male or Female

Country of Birth: _________________ Country of Citizenship: _______________

Mailing Address for I-20:________________________________________________

______________________________________________________________________

Postal Code:_____________________ Country: ______________________________

Student's Home Address (if different): ____________________________________

______________________________________________________________________

Postal Code:_____________________ Country: ______________________________

Telephone Number: ______________________ Fax Number: ____________________

E-Mail Address: ________________________________

I would like to attend the MLC intensive English program beginning month__________, year______. I am enclosing the $100.00 non-refundable advanced tuition deposit or the MasterCard/Visa Authorization Form. The $100.00 non-refundable deposit will be applied to my first term's tuition. Please send me the Form I-20.

STUDENT SIGNATURE__________________________ Date:_________________

(If you plan to come to the United States with dependents, please notify the MLC.)

UNIVERSITY TOWERS HOUSING REQUEST FORM AND CONTRACT

__ Do not reserve housing for me.

__ I would like to reserve a shared bedroom at University Towers.  I understand that I will share 1 bedroom in a 2-bedroom apartment, and that the 2nd bedroom will have 1 or 2 other students.  I understand that the cost of a shared bedroom is $825.00 per 6-week term* and $550.00 per 3-week term. I am enclosing the total amount of the housing fee by US check or by MasterCard/Visa Authorization Form.

__ I would like to reserve a single bedroom at University Towers.  I understand that I will have my own bedroom in a 2-bedroom apartment, and that the 2nd bedroom will have 1 or 2 other students.  I understand that the cost of a single bedroom is $1325.00 per 6-week term* and $795.00 per 3-week term. I am enclosing the total amount of the housing fee by US check or by MasterCard/Visa Authorization Form. (There are a limited number of single rooms available.)

*Housing costs are subject to change

__ OPTIONAL BED & BATH PACKAGE: Please reserve an optional Bed & Bath Package for me. The cost of a Bed & Bath Package is $65.00. I understand that I must reserve a Bed & Bath Package in advance and that the package contains the following: Blanket; Pillow; Pillowcase; Bath towel; and Hand towel. These items are sold as a package. If a student does not reserve a Bed & Bath Package in advance, the student should bring these items from his/her own country.

ADDITIONAL HOUSING RELATED CHARGES PER PERSON

Utility Charge: 6-week term=$60.00/person

                           3-week term=$40.00/person

Cleaning Fee: $30.00/person for each 3-week or 6-week term

Refundable Key and Damage Deposit: When a student first moves into University Towers, a $150.00 refundable damage deposit is collected from each student to cover the cost of the keys and damage to the apartment. The deposit is returned to the students within 30 days after the student leaves the apartment if the keys are returned and there is no damage to the apartment.

I have agreed to rent either a shared or a single bedroom for the term stated on the application on the other side of this page. I understand that if I have reserved a shared or a single bedroom at University Towers and I have entered the United States, I am responsible for paying the total housing fee for the term unless I cancel my reservation in writing 14 days prior to the published University Towers move-in date. If I continue to study at the MLC for additional terms, I will have the option to continue to rent at University Towers or to arrange my own housing.

STUDENT SIGNATURE__________________________ DATE_________________

STATEMENT OF FINANCIAL RESPONSIBILITY

Applicant's Name (Typed or Printed)_____________________________________________________

I understand that the tuition at the Michigan Language Center is $1250.00* for each six-week term, and books cost approximately $125.00 per six-week term. Living expenses are estimated to be between $1465.00 and $2000.00 for each six-week term. Therefore, an intensive student at the MLC should have at least $2840.00 available to him or her for each six-week term of study to pay for tuition, books and living expenses. I agree to be responsible for these expenses.

Signed___________________________________________________Date_______________________

* Tuition is subject to change.

MASTERCARD AND VISA CHARGE AUTHORIZATION FORM 

Check One: Mastercard Or Visa 

As the cardholder, I give my permission for the following charges to be made on my credit card: 

DHL Express Mail Courier charge of $_________________________
            *DHL prices change very frequently.  Please contact the MLC for DHL rates.

Other __________________________________________________________________

TOTAL AMOUNT TO BE CHARGED:________________ 

Account Number:#__________________________________ 

PLEASE READ AND SIGN:
I understand that the Application and Advance Tuition Fee and the Housing Deposit and Reservation Fee are Non-Refundable. 

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Michigan Language Center
309 S. State St.
P.O. Box 8231
Ann Arbor, MI 48107, U.S.A.
Tel: (734) 663-9415
Fax: (734) 663-9623
E-Mail: mlc-usa@att.net