IEI Daytime Intensive Program Application

Intensive English for Internationals

Better English. A Better Future.

Please enter your first name(s) and last name(s) in the form below as written on official documents (passport, drithen vers license, etc.)
Please do NOT use all uppercase letters.

First Name

Middle Name

Last Name

What is your birthdate?

Year

Month

Day

What is your gender?

Male Female Other

What is your race?

1-White
2-Black or African American
3-Asian
4-American Indian
5-Alaskan Native
6-Native Hawaiian or Other Pacific Islander
Unknown

What is your ethnicity?

What is your first language?

What is your country of citizenship?

What is your country of birth?

What is your city of birth?

Please select which one of the following best describes your status:

If you are not a US Citizen or Permanent Resident, what type of visa will you use to study?

What is the expiration date of your visa or green card? Please leave blank if you do not have one.

Year

Month

Day

Do you need an I-20 to apply for an F1 visa or to transfer to IEI from another school?

Yes No

What is your email address?

What is your phone number?

Check this box if you do not have a US phone number.

US Telephone Number

Check This box if you do not have a foreign phone number.

Country Code

Foreign Telephone Number

What is your address?

Check this box if you do not have a US address.

US Street 1

US Street 2

US Street 3

US City

US State

US Zip Code

Check this box if you do not have a foreign address.

Foreign Street 1

Foreign Street 2

Foreign Street 3

Foreign City/State

Foreign Postal Code

Foreign Country

Who is your Emergency Contact?
(By including this information, you are giving IEI permission to communicate with the person listed regarding all issues surrounding your IEI experience, including, but not limited to, account, academic, immigration, conduct, health, and safety information.)

First Name

Last Name

Relationship

Phone

If you studied in IEI or at the University of Memphis in the past, you received a student ID number. (Example: U00123456)
If you have a University of Memphis student ID number, enter it here.

UofM Student ID number (ex: U12345678)

If you studied in IEI or at the University of Memphis in the past, you received a UM email account. (Example: tomtiger@memphis.edu)
If you have a University of Memphis email address, enter it here.

UofM Email address

Are you on a SACM (Saudi Arabian Cultural Mission) Scholarship?

Yes No

Please choose the program for which you want to apply.

When would you like to begin your study?

I hereby certify that the above information is correct and that I will abide by the regulations for students in the Intensive English for Internationals program at The University of Memphis.