English Language Institute (ELI) Application

Academic History Previous School (if applicable)

Second College/University/High School

School Country

School City

Level of Study

Start Date

End Date

Major

Degree Earned/Expected

Date of Graduation/Expected

Emergency Contact Information

Given Name (First Name)

Surname (Last Name)

Phone Number

Email Address

Relationship

Additional Information

Do you require a student visa?

Are you already in the U.S.?

Immigration or visa status:

Are you using a consultant or agency to help you with the application process?

Please select the Consultant or Agency you are using. If you do not see it, you can leave this blank.

Do you plan to attend an academic program at the University of Bridgeport after finishing ELI?

Signature

Signature

My signature below indicates that all the information contained in this enrollment form is complete and correct. I am aware that any falsification in the completion of this enrollment form, either by error or omission, may result in my being denied enrollment by the University of Bridgeport or may result in disciplinary action. By providing my signature, I grant the University of Bridgeport permission to obtain my official transcript from my high school as well as verify my qualification for free and/or reduced priced meals.

Signature

Signature Date