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Application for Admission

– Step 1 of 3

Personal Information

Name *

First

Last

Email *

Confirm Email

Phone *

Date of Birth *

Gender *

Male
Female

How did you hear about us. *

If Friend/Family or Other, please specify. *

If you are referred by an agency, please state the name of the company.

Do you have or need an F-1 visa? *

An F-1 visa is a non-immigrant visa for those wishing to study in the U.S.

What is your status? *

Initial (I want to go to the US. I need an F-1 visa.)
COS (I am in the US. I want to change my visa to F-1.)
Transfer (I have an F-1 visa. I want to transfer.)

Country of Birth *

City of Birth *

Country of Citizenship *

Where are you staying? *

In the US
Outside the US

U.S. Address (Your home address in the U.S.) *

Address Line 1

Address Line 2

City

State

Zip Code

Foreign Address (Your home address outside the US.) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mailing Address (Complete if different from the above.)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have dependents you want to add on your Form I-20? *

Dependents are spouses and/or unmarried minor children. Children 21 years of age or older are not eligible to enter as the dependent of an F-1 student.

If Yes, how many dependents? *

One
Two
Three
Four or more

Dependent 1

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *

Country of Birth *

City of Birth *

Country of Citizenship *

Dependent 2

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *

Country of Birth *

City of Birth *

Country of Citizenship *

Dependent 3

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *

Country of Birth *

City of Birth *

Country of Citizenship *

Additional Dependents

Please list additional dependents in the same format. *

Program

Which type of courses? *

Online
Offline (Face-to-face)

Which School Location? *

POLY Languages at Irvine
POLY Languages at Los Angeles

Even if you chose the Online option, you still need to select the school where you wish your records to be kept.

Which Program? *

General Courses
Private/Group Lessons

For General Courses, students must be 17+ years of age. For Private/Group Lessons, students must be 12+ years of age.

When would you like to start? *

How many weeks do you plan to study? *

Our terms are 4 weeks long.

How many hours per week? *

For pricing, refer to Tuition and Fees.

How many hours per week? *

For pricing, refer to Tuition and Fees.

Housing Service

Do you need housing?

Our Housing Arrangement Service is available only for incoming international students from overseas. The service fee is $200, non-refundable.
To ensure timely housing arrangement, please make your request at least 30 days before your desired move-in date. We recommend contacting us as soon as you obtain your F-1 visa and submitting the security deposit and first month’s rent.
The security deposit is $400, due 20 days prior to your scheduled move-in date. The average monthly rental rates are $1,200/month for accommodation without meals and $1,550/month for accommodation with breakfast and dinner included. It’s important to note that these rates may vary depending on the host families available.

Are there any health problems, allergies, or concerns that you would like us to be aware of?

The information you provide above may be disclosed to the relevant parties involved in your housing, if deemed necessary.

Private/Group Lessons

Private/Group Lessons *

By checking the box for Private/Group Lessons, I agree and understand that a member of our Faculty Support Team will contact me within 7 days to provide an orientation and arrange a suitable teacher for me. During the orientation, I will take an English assessment test and specify the English skills I want to focus on. I also understand that the start date provided in this application is only an estimate, and an exact start date must be scheduled with the assigned teacher. For online lessons, I understand that lessons must be scheduled between 7:00 am and 9:00 pm, Monday to Friday. For face-to-face (offline) lessons, I understand that lessons must be scheduled between 2:00 pm and 4:00 pm, Monday to Thursday.

How many lessons? *

Each lesson is 80 minutes long.

How many students? *

There is a charge of $60 per student per term (4 weeks).

Which days? *

Monday
Tuesday
Wednesday
Thursday
Friday

Check the day(s) you are available for the lessons. For online lessons, the lessons can be scheduled between Monday and Friday. However, for face-to-face (offline) lessons, the lessons must be scheduled between Monday and Thursday.

Which start time? *

What time of the day(s) is the best for you to start your lessons? For online lessons, the lessons can be scheduled between 7:00 am and 9:00 pm in Pacific Time. However, for face-to-face (offline) lessons, the lessons must be scheduled between 9:00 am and 4:00pm in Pacific Time.

Note/Comment

Tuition and Fess

Application Fee (F-1) *

$150 (non-refundable)

Application Fee *

Handling Fee *

$80 (non-refundable)

Housing Arrangement Service *

$200 (non-refundable)

Student Visa Assistance Service (F-1 Initial) *

$250 (non-refundable)

The Student Visa Assistance Service includes the following:
* We assist you in in completing the SEVIS Form I-901.
* We assist you in completing the Visa Application (Form DS-160).
* We assist you in scheduling and preparing for your F-1 Visa Interview.
* We can send you another acceptance packet free of charge if your visa is rejected.

Total Due *

$ 0.00

Once you’re accepted, we will assist you with all aspects of the admission process.

Assisted by (Optional)

Stated the name of the advisor who assisted you in completing this form.

Stripe Credit Card *

Card

Name on Card

Acknowledgement and Agreement *

By checking the box and submitting this Application for Admission, I confirm that I have reviewed the digital School Catalog and agree to comply with all its terms and conditions. I acknowledge that I am fully responsible for all expenses incurred during my enrollment at POLY Languages Institute and for any actions taken during excursions or other activities. I understand and accept all associated risks and release POLY Languages Institute from any liability arising from harm or injury sustained during these activities.
In case of an emergency requiring medical examination and treatment, I grant permission to POLY Languages Institute to contact an appropriate medical center on my behalf. I understand that this action is taken solely in my best interest and for my well-being.

Name