Application Form

To apply to Internexus, complete the following application:

Which center do you want to attend?
Provo (US)
Indianapolis (US)
Salt Lake City (US)

Which course do you want?
Intensive English
Semi-Intensive English
Intercultural
Special Program (list name):

How many weeks do you wish to attend?

Which date do you wish to start?


Do you need a student visa (F1)?

(Student visas are required for all USA Intensive English Programs over 18 hours per week. You will be issued an I-20 if you need a student visa.)

Family name:
First Name:
Middle Name or Inital:
Birth Date:

Sex:



Marital Staus (optional):
Single
Married

Country of Citizenship:
Country of Birth:

Present Phone:
Home Phone:
Fax:
E-Mail address:

Parents' Guardians' Names (if you are under 18 years old):

Mailing Address: (if you need a student visa, please fill this with your home country address)
Street:
City:
State:
Country:
Postal Code:

If you need an I-20 for a dependent please fill in the following information:
Dependent's Name:
Dependent's Date of Birth: Dependent's Country of Citizenship:
Dependent's Sex:
Dependent's Relationship to you:

Do you need airport pick-up service?
Yes (if yes do you need Arrival Departure)
No

Insurance Information (Health insurance is required at all U.S. Centers.)
I will have my own health insurance:
Company Name:
Policy Number:
Expiration Date:
I would like to purchase insurance though the Internexus Center (First Month: $95, Following Months: $85) How many months?

What kind of accommodation do you need?
Homestay
Dorms (Cedar City and Indianapolis only)
Apartment (Indianapolis only)
I don't need accommodation.


What is the arrival date at the accommodation?
and the departure date from accommodation:

How did you hear about Internexus?
Friend/Relative
Internet - Which Site?
Study Abroad Fair
Magazine/Newspaper Ad - Which one?
Former Student - Who?
Agent:
Name:
Address:
Telephone:
Fax:
E-Mail:
Other - Explain:

Do you have any other special requests or concerns?

By clicking on the submit button below, you acknowledge and agree to our enrollment rules and policies.