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 (Family Name)                                                FIRST

Telephone    Day________________ Evening __________________

Address ___________________________________________

City _______________________ State _____ Zip_________

Fax Number _______________________________

E-mail ____________________________________

Native Language ____________________________

___ Male
___ Female

English Language Level

____ Intermediate
____ Advanced

____ Check here if you have previously enrolled in an Evening English Program course at Rice University.

Please check the session you prefer:

____ Winter: January 21-March 17
____ Spring: April 6-June 1
____ Summer: June 17-August 11
____ Fall: September 23-November 17

Schedule: Students are assigned class days and times based on their proficiency levels and space available.

Please indicate days and times you might prefer:

____ 5:45-7:15 p.m. Monday and Wednesday
____ 7:30-9:00 p.m. Monday and Wednesday
____ 5:45-7:15 p.m. Tuesday and Thursday
____ 7:30-9:00 p.m. Tuesday and Thursday

Are there certain days or times when you cannot attend?

___________________________________________

Choose the one skill you want your class to emphasize:

____ Speaking ____ Grammar* ____ Pronunciation* ____ Writing*

*Offered at the advanced level only

Payment and Refund Information:

A payment of $370 must accompany this form. Refunds will be made only upon written cancellation received by the application deadline or upon cancellation of the class by Rice University.

I understand and agree to the refund policy:

Signature____________________________________ Date__________________

Payments may be made by check or money order payable to Rice University. MasterCard, VISA and American Express credit cards are also accepted. Please include your credit card information below.

Refunds for credit card payments will be processed as credits to the accounts from which they were paid and may not appear as a credit until the following statement. Refunds for enrollments paid by check take up to four weeks to be processed and mailed by the Rice University accounting office.

There is a $30 charge for any check returned for insufficient funds.

Method of Payment:

___ Check or money order enclosed (payable to Rice University)
___ Please charge to my:

_____VISA _____MasterCard _____American Express

Card Number__________________________________

Card Holder's Name ____________________________

Expiration Date ________________________________

Signature _____________________________________

Amount to be Charged $__________________________