| __________________________________________ | _______________________________________________ |
| Family Name | Given Name |
Gender: Male Female
| ___________________________________________________ | ______________________________________ |
| Street | City |
| ___________________________________________________ | ______________________________________ |
| State | Zip Code |
Birth date (month/day/year): ________________________________
Birthplace (country) : ______________________________________
University ID Number (if you have one) _______________________
Country of Citizenship ______________________________________
Native Language __________________________________________
Telephone _______________________________________________
E-mail address ____________________________________________
How or where did you hear about the IIEP? Choose one: Friends Former IIEP student web site (which web site?) _________________________________________________ Other (please specify) ________________
Are you enrolled in other courses at The University of Iowa (including post-doctoral research) or in the Saturday and Evening Program? yes no
Formal Instruction in the English Language:
Number of years in Secondary School _______ In College or University _______
Other ______
Have you taken the TOEFL exam? yes no. If yes, what was your score? _________
What type of visa do you hold?
Student (F-1, F-2)
Exchange Visitor (J-1, J-2)
Tourist (B-1, B-2)
Other __________
What is the expiration date on your Form I-94? _________________________________________
Mail or bring this application, along with a $100 tuition deposit to:
Iowa Intensive English Program
1112 University Capitol Centre
The University of Iowa
Iowa City, IA 52242-1322
Note: If your department will sponsor you, please contact our office at 335-5630 to obtain a Departmental Payment form; in this case, a tuition deposit is not required.
After we have collected the applications,
we will contact you by e-mail to let you know when and where the class will meet.
©The University of Iowa (2004). All rights reserved.
Revised August 2006