Wufoo

Eurocentres Silicon Valley

All boxes designated with a red asterisk are required. Please fill out all other boxes to the best of your ability.

Section 1
Personal
Last Name (Family Name) *
First Name *
Middle Name
Date of Birth * MM / DD / YYYY
Sex *
Male Female
Occupation
Country of Birth *
Nationality *
Student's Address in Home Country *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

All boxes must be filled. If a box can't be filled, write "0" in it.
Student's Address in U.S. (if known)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Address in Home Country *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

All boxes must be filled. If a box can't be filled, write "0" in it.
Telephone *

Write numbers without spaces.
Fax
E-mail *
Previous English Study in Years
International English exams already taken

If question does not apply, please skip next question.
Exam mark received
Future study plans in Menlo Park, CA, USA
How did you learn about Eurocentres Silicon Valley? *
Language Skills (10 being the highest) *

What is your own assessment of the present level of your English proficiency (Refer to Scale of Language Proficiency in the Enrolment Guide for levels).
SECTION 2
Course

All fields in this section are required
Course Choice *
Basic 20 Specialized Intensive 25 Specialized Super-Intensive 30
Course Start Date * MM / DD / YYYY
Monday Start Dates
January-07,14,21,28
February-04,11,18,25
March-03,10,17,24,31
April-07,14,21,28
May-05,12,19,26
June-02,09,16,23,30
July-07,14,21,28
August-04,11,18,25
September-01,08,15,22,29
October-06,13,20,27
November-03,10,17,24
December-01,08
Course Length (Weeks) *
Number of One-to-One Lessons
Would you like to take an Examination Course? *
Yes No
If so, which one?
Section 3
Visa
I need the student visa (F-1) and require the I-20 form. *
Yes --If yes, complete Section 3. No --If no, skip to Section 4.
I will enter from
If already residing in the U.S., what visa type do you currently hold?
What is your admission number ?
If on an F-1 visa, which school issued your most recent I-20? (School Name)
School fax number ### - ### - ####
I will, while in the United States, have $___, in the following account(s).

Please visit www.xe.com for the current exchange rates.
Personal funds $ Dollars . Cents
Family funds $ Dollars . Cents
Other funds $ Dollars . Cents
A copy of the bank statement or other document will be sent:
By email to info@eurocentres-sv.com By fax to (650)321-2510 By mail to 585 Glenwood Avenue, Menlo Park, CA, 94025
Section 4
Accommodation

Please consult the homestay information and fees and dates sections of the website for further information.
Accommodation *
I will arrange my own accommodation --skip to Section 5. I would like Eurocentres Silicon Valley to arrange my homestay accommodation --complete Section 4.
With the homestay, I want (check one)
Breakfast and dinner No meals/kitchen use
Arrival Date MM / DD / YYYY
* Accommodation for Eurocentres is always reserved from Saturday-Saturday
Departure Date MM / DD / YYYY
Would you like Eurocentres to arrange transfer from the airport on arrival? (See the fees section of the website for further information.) *
Arrival Date MM / DD / YYYY
Airline and flight number
Do you have any special requests related to medical conditions, allergies or diet?
If yes, please list below.
Do you smoke?
Would you be comfortable with a host that smokes?
Please list your personal interests and hobbies
SECTION 5
Insurance

All international students must have adequate travel and medical insurance . An English translation must be provided on your first day.
*
I would like Eurocentres Silicon Valley to provide me with information about insurance I will arrange my insurance policy before leaving my home country
Section 6
Payment

All registration and homestay fees are nonrefundable.
Please visit WWW.XE.COM for the current exchange rates.
Payment Options (Non Credit Card)
Bank wire transfer: Please contact us for information. Money order: mail to Eurocentres Silicon Valley, 585 Glenwood Avenue, Menlo Park, CA, 94025, USA
Payment Options (Credit Card)
Visa Master Card American Express
Name as It Appears on the Credit Card First Last
Credit Card Number

XXXX-XXXX-XXXX-XXXX
Expiration Date (Month/Year) MM/YYYY
Application Fee $ Dollars . Cents
$115.00 Non-refundable
Homestay Placement Fee $ Dollars . Cents
$95 Non-refundable
Airport Pickup Fee $ Dollars . Cents
$75 each way, non-refundable.
Total $ Dollars . Cents
Section 7
Declaration

You have completed the application form. Please read over your submission and make sure you answered all the required fields (those labeled with a red asterisk.)
I have read the Code of Practice Summary and accept the Conditions of Enrolment. *
Yes
Do Not Fill This Out

Wufoo

Eurocentres Silicon Valley

Section 1 Personal

SECTION 2 Course

Section 3 Visa

I will, while in the United States, have $___, in the following account(s).

Section 4 Accommodation

SECTION 5 Insurance

Section 6 Payment

Section 7 Declaration

Section 1
Personal

SECTION 2
Course

Section 3
Visa

Section 4
Accommodation

SECTION 5
Insurance

Section 6
Payment

Section 7
Declaration