A DMIS S IO N AP P LI CAT IO N FO R M

Please print clearly.

1.*Family Name:

2. First Name:

3. Middle Name:

4. Suffix:

5. * Date of Birth (MM/DD/YYYY):

6. * Gender:

7.* Country of Birth:

8. * Country of Citizenship (If you have dual citizenship, choose the citizenship of the passport you will use to enter the US):

9. US Driver’s License Number and Issue State (If applicable)

10. Social Security Number (If applicable)

11. Individual Tax-Paper ID Number (If applicable)

12. *Foreign Address:

Address 1

Address 2

City Province/Territory Postal Code Country

13. US Address (Address where student will be staying in the US – if you do not have this information, this can be completed at a later time):

Address 1

Address 2

City State Zip Code

14. *Education Level:

If other enter here:

15. Current English Level

16. *Normal Length of Study (Months)

17. *Desired Start Date (MM/DD/YYYY)

18. *Program Start Date

19. *Program End Date

20. *Number of months in academic terms

21. Funding
*Students Personal Funds (in US Dollars)

Funds from other sources (in US Dollars)

*Total funding

*Proof of Financial Responsible (please attach documentation)

22. Student signature:

23. Date:

Please scan all documentation and e-mail to info@mindfuelschool.com

If you have any questions, you can contact Peggy Classe at info@mindfuelschool.com or
786-356-2679 – (text messages and/or WhatsApp messages are available on this number)