You can either print this page and complete the application by hand or use this fill-in PDF form, then mail or fax your application to:
Rice University
Glasscock School of Continuing Studies
Language Programs – MS 550
P. O. Box 1892
Houston, TX 77251-1892
Phone: (713) 348-4019
Fax: (713) 348-5213
Name________________________________________________
Last First Middle
Houston Telephone Numbers:
Day ________________________________
Evening _____________________________
U.S. Street Address (not P.O. box) Include Zip Code:
_______________________________________________________
Street Address
_______________________________________________________
_______________________________________________________
City State Zip Code
Foreign Address:
_______________________________________________________
Street Address
_______________________________________________________
_______________________________________________________
City Province Country Postal Code
Telephone _________________________________
Fax Number________________________________
E-mail_____________________________________
Country of Birth_____________________________________
Country of Citizenship_________________________________
Birthdate_______ /___/______
Type of Visa _______________ (month/ day/ year)
___ Male ___ Female
Indicate the highest level of education you have achieved:
Institution Name________________________________
Degree Received ___________________ Date _______
How many sessions do you plan to study in the Rice University Intensive English Program?______
Please check the first session you plan to attend:
2009
___ January 5-March 2
___ March 3-April 29
___ April 30 -June 25
___ June 26-August 21
___ August 31-October 26
___ October 23-December 18
Please indicate your major reason for enrolling in the Rice University Intensive English Program:
___ I plan to attend a college or university in the United States. I plan to attend the following type of program (check one):
___ Associate (two-year) degree program
___ Bachelor's (four-year) degree program
___ Master's degree program
___ Doctoral degree program
___ I am studying English for non-academic reasons such as for general communication, professional or language training purposes.
Tuition refund policy
The $60 testing and registration fee is non-refundable. New students withdrawing by 4:00 p.m. of the last business day before the first day of class (see
schedule)will receive a refund of $440 from the $500 deposit.
Returning students who withdraw after the discount deadline and by 4:00 p.m. of the last business day before the first day of class will be charged a $50 cancellation fee. They will receive a refund of $1390 from the $1440 tuition fee.
Students withdrawing by 4:00 p.m. of the tenth day of class will receive a refund of one-third of their tuition. (Students who have paid $1490 will receive a $500 refund. Returning students who have paid $1440 will receive a $480 refund.)
There is no refund for any student withdrawing after the tenth day of class.
All withdrawal requests must be made in writing.
I understand and agree to the refund policy.
Signature____________________________________
Date________________________________________
Express Delivery of I-20
To authorize express delivery of the I-20 form, sign below. Express charges must be paid by student in addition to tuition.
Signature____________________________________
Date________________________________________
A deposit of $500 ($440 of which will apply to the tuition fee) must accompany this form.
Payments may be made by check or money order, payable to Rice University. Credit cards (MasterCard, VISA, or American Express) are also accepted. There is a $30 charge for any check returned for insufficient funds.
Credit Card Registration _____MasterCard _____VISA _____American Express Card
Number____________________________________
Card Holder's Name_______________________________
Expiration Date___________________________________
Amount Charged__________________________________
Signature________________________________________