REGISTRATION FORM

Please complete this form and return to LCI English Center. International students need to include a total non-refundable fee of $270 ($120 registration fee and a $150.00 tuition deposit).

Personal Information Last Name ____________________First Name _______________Middle ____________ Gender _____ Birth date (month-day-year)_____________Telephone (___)___________e-mail____________________ [IF APPLICABLE]: Name and address of your company or, if a scholarship student, name of embassy, advisor and student number:________________________________________________________________ _______________________________________________________________________ Telephone (___)____________Fax (___)_____________ Home Country Address Street _________________________________________City______________________ State____________ Postal Code____________ Country__________________________ United States Address (if applicable) Street __________________________________________________________________ City______________________ State____________ Postal Code____________

Only the full-time English programs qualify students to receive the I-20 form. Do you need an I-20? No______ Yes_____. If yes, you must submit the following: 1. Completed and signed registration form including appropriate registration deposit and fees 2. Certification that sufficient funds are available to meet tuition costs and living expenses. Any of the following are acceptable: a) A current bank statement or a letter from your bank certifying that you or your sponsor has sufficient funds. b) A notarized affidavit of support LCI English Center must receive all appropriate documents and payments in full before the I-20 is issued. Upon receipt of the above we will send an invoice with the final amount due. _____ Please send my I-20 by Express Courier for an additional fee of $ 70.00 _____ Please send my I-20 by Overnight Express Courier for an additional fee of $150.00

Course Fees and Services Classes canceled in honor of local holidays will not be made up and are not subject to any refund. You may select from 2 to 52 weeks. Program Selection ______General English Program ______Academic English Program ______University Preparation Program ______Executive English Combo Program ______Executive English Full Immersion ______IELTS Preparation Program ______TOEFL Preparation Program ______GRE Preparation Program ______GMAT Preparation Program ______Other Program : ______________________________ ______ Accent Reduction Program

General English, Business English, and Test Preparation sessions begin every Monday. Private classes can be scheduled any day, between the times of 9am to 7pm. Start date:___________ End date: _______________

Academic English Program terms are for 9/10 weeks each with the following start dates:

( ( (
(

) OCTOBER 2010 TERM: ) JANUARY 2011 TERM: ) MARCH 2011 TERM:

) MAY 2011 TERM:

Start October 18th- End December 24th Start January 4th - End March 11th Start March 21st End May 27th
Start May 30th End July 29th Start August 8th October 14th Start October 17th December 23rd

( ) AUGUST 2011 TERM: ( ) OCTOBER 2011 TERM:

Please fill out the breakdown in fees. You may refer to your quote from an LCI representative. TOTAL COSTS Registration Fee Tuition Books Accommodation fees I-20 Express courier Airport transfer Health Insurance Dental Insurance Car Rental Total $ ______ $ ______ $ _______ $ ______ $ ______ $ ______ $ ______ $ ______ $ ______ $ ______

Payment Options Please check one. Bank Wire Transfer______ Bank Name: Swift code: Bank Address: Wells Fargo WFBIUS6S 8980 E. Hampden Ave. Denver, Co 80231 720-493-2815 102000076 LCI English Center 9323878653

Colorado ABA # Beneficiary account name: Beneficiary account#:

Wells Fargo Headquarters Information: on om nF n o ABA # 121000248.

Credit Card Charge Authorization______ Card Type ____________________ d d Hold N m ____________________________________________

Credit Card # ______________________ CVV: ___________ Expiration Date: ____/____ I authorize LCI to charge the amount of $_______ Signature _____________

Accommodations Options _____ Host Family _____ Hotel _____ Apartment _____ None Date of Arrival ___/___/____ Date or Departure ___/____/____

If you would like to stay with a host family, please answer the following questions:

1. Do you have any allergies? 2. Would you mind a dog or a cat in your lodging? 3. Is this your first time abroad? 4. Are you a vegetarian or vegan? 5. What do you expect from your host family? 6. Comments

Your English Level & Objectives Do ou p k En l h wo k? Y/N hool? Y/N wh n ou v l? Y/N w h f nd ? Y/N

How good is your English now? ___ Poor ___ Good ___ Very Good ___ Excellent What do you want to learn?

Flight Information (optional) Flight # _______ Airline _________ Arrival Date and Time___________
Refund Policy
A full refund less non-refundable deposit and courier fees will be made if cancellation or no show prior to course start date. Refund will be issued within thirty (30) days of the first class or LDA (last date of attendance). First session - Four weeks or less: No refund will be made for students who register for four weeks or less and then withdraw within the session. First session Greater than Four weeks: For students who withdraw at any point in the first four weeks, LCI will retain the charges applicable to the first four weeks. If a student withdraws after the first four weeks but before or at midpoint of the session LCI will retain the prorated amount of tuition. If a student withdraws after midpoint LCI will retain all the charges for that session. Private classes may be rescheduled with at least 24 hrs advance notice. Classes cancelled in less than 24 hrs will be charged. HOMESTAY REFUND POLICY: If LCI English is unable to find suitable accommodations, we reserve the right to withdraw our offer to provide housing. All prepaid fees will be refunded. If a student withdraws his/her application for housing prior to the specified date, all prepaid fees less a $150.00 non-refundable service charge will be returned. If student does not show up on arrival day without informing LCI and had requested airport pick-up, the $ 60.00 airport transfer will not be refunded.

I understand that LCI is only bound to provide services as described in the written literature and no oral representation made by agents or school staff is valid.

_____________________________ Signature of Student

_________________ Date