Haggerty English Language Program, Center for International Programs

Haggerty English Language Program

Application Form

Please complete this entire application, which will go to our office. We will keep the information until we receive all required items: $50 application fee, financial statements, and school transcripts (proving that you have completed high school). Our address appears at the end of this application.

If you have questions you can e-mail us at any time (esl@newpaltz.edu). We will not process any application until all the items we require are received.

2. Type your name as it appears on your passport:

Family Name:
Given Name:

3. Home Address:

Street:
City:
State/Province:
Country:
Code:

4. Telephone (include country code, city code, and number):
Fax (include country code, city code, and number):

5. Date of Birth (month/day/year):

6. Place of Birth:
City:
Country:

7. Gender:
Male
Female

8. Country of Citizenship:

9. If you are already in the U.S., what is your immigration status?
B-1
B-2
J-1
J-2
Other

10. If you have a U.S. Social Security Number, what is it:

11. I am a high school graduate:
Yes
No

12. I will need to live on campus:
(You must be at least 17 years of age to live on campus.)
Yes
No

13. Are you transferring from another school in the U.S.?
Yes
No

If yes, school name:

14. Address for you or a contact person in the U.S., if any:

Family Name:
Given Name:
Street:
City:
State:
Zip:
Telephone:
Fax:

15. How did you learn about HELP? Check all that apply:
Friend/Relative -- Name:
Agency -- Agency Name:
Advertisement -- Publication:
Fair -- City:

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