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Kansas State University

Application

 

Instructions: Please print this application, complete all sections and mail to:

American Language and Culture Certificate Program
English Language Program
205 Fairchild Hall
Kansas State University
Manhattan KS 66506-1106 U.S.A.
Phone: 01-785-532-7324 Fax: 01-785-532-6550
E-Mail: elp@ksu.edu

If you have problems filling out the form, check the help page at www.ksu.edu/elp/classes/appinstr.htm

First Name:                                                                 

Middle Name:                                                            

Last Name:                                                                 

  • Other last name under which records may be found at Kansas State University.                                                 
  • If you have records at other institutions under different last names please tell us how many other last names.                                                  
Social Security: #                                                       

E-mail address:                                                          

Birth date:                                                  
                  Month  /  Day  / Year

Place of birth  City                                       Country                                                       

Country of Citizenship                                                      

Address information:
Mailing address (All K-State correspondence prior to the beginning of classes will be mailed to this address. Please do not use any punctuation; please use only alphabetical letters, numbers, and spaces, in accordance with U.S. Postal conventions.)
Street                                                                                            Telephone                                                   
Street                                                      
City                                                           
Country                                                     Postal code                            
Permanent or family address: (please do not use any punctuation)
First Name                                                       Middle Name                                                       Last Name                                                      

             Parent             Spouse             Legal Guardian             Nearest Relative             Other 

Same address as above?              Yes            No  (If NO, please fill in the address)

Street                                                                                            Telephone                                                   
Street                                                      
City                                                           
Country                                                     Postal code                            

Other personal information:
Have you graduated from High School?               Yes            No
Are you or have you attended university?               Yes            No
Are you an exchange student?                               Yes            No

Are you a U.S. Citizen or Permanent Resident?                 Yes           No
Is English your primary language?                                    Yes           No
Do you have a TOEFL score?                                         Yes           No

If yes, what was the score?                               

If you have no TOEFL score or if your score is below 550 / 213 CBT, then you may need to enroll in intensive English classes before you begin the Certificate Program.  This will add time and expense.

Gender:                      Male               Female
Marital Status:            Married           Single

If you are married and will bring your family with you, please be sure to include the name, relationship to you,
date and country of birth for each person coming with you. Send this information by e-mail, fax or regular mail.

Your Academic plans:

Are you applying to the American Language and Culture Certificate Program?           Yes            No

Do you plan to complete a Bachelor's Degree at K-State?           Yes           No  

This is the application for the American Language and Culture Certificate.  If you are planning to complete a Bachelor's degree in addition to the Certificate, you must fill out the application at  www.ksu.edu/admit

Have you ever taken any college or university course work (other than at Kansas State University)?           Yes           No
Are you now taking college classes?           Yes           No


          Number of Colleges/Universities

          August,            (year)

          January,           (year)

           June,              (year) (If you are planning to come in summer to do intensive English because your TOEFL score is below 550 / 213)

If you have any questions, e-mail them to elp@ksu.edu

Credit Card Information

Complete below if you wish to pay your application fee with a credit card. 

VISA            MASTERCARD

Card # Exp. Date

Cardholder's Name