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APPLICATION FORM Fields marked with are required.*
STUDENT INFORMATION
First Name*:		Middle Name:
Last Name*:		Gender*:	Male Female
Date of Birth*: (Day/Month/Year)	- -	Country of Citizenship*:
Country of Birth*:
Current Address:
Street & Number*:		City*:
State/Province*:		Postal Code*:
Country*:		Phone*:
Fax:		E-mail:
Emergency Contact:
Name*:		Relationship*:
Tel*:
*Status in the U.S.:**
Visa Waiver	B2 Visitor Visa	Permanent Resident of the U.S.	F-1 Student Visa
Others, explain:
Hawaii Address & Phone (If known):
Street & Number:		City:
State:		Zip Code:
Phone:		Country:
PROGRAM INFORMATION
Start Date*: (Day/Month/Year)	- -	End Date*: (Day/Month/Year)	- -
English Programs:
Approximate Current Level of English:
ACCOMMODATION
Type of Accommodation*:
Start Date: (Day/Month/Year)	- -	End Date: (Day/Month/Year)	- -
If you apply for a hotel, please answer the following question.
Type of Room preferred:	Standard	Kitchenette
If you apply for a apartment/condominium, please answer the following question.
Type of Room preferred:	Studio	One-bed Room	Two-bed Room
If you apply for a homestay, please answer the following questions.
Do you smoke?	Yes No
Do you have any allergies?	Yes No	If yes, please describe:
Do you take any medications?	Yes No	If yes, please describe:
Do you have any special dietary requirements?	Yes No	If yes, please describe:
Do you have any hobby or particular interest?	Yes No	If yes, please describe:
Can you live with pets?
Can you live in a family with children?
AIRPORT TRANSFERS
Do you require airport pick-up?*	Yes No	Do you require airport drop off?*	Yes No
If yes, please identify		If yes, please identify
Arrival Date:(Day/Month/Year)	- -	Departure Date:(Day/Month/Year)	- -
Airline:		Airline:
Flight Number:		Flight Number:
Arrival Time:		Departure Time:
Departure from:		Departure to:
PAYMENT INFORMATION
Please indicate the form of payment.*
Credit Card (Please fill out information below)		Wire Transfer Bank Draft/Check	Other
Credit Card Number:
Credit Card Company:	Visa Mastercard	JCB Diner’s Club	American Express
CardHolder’s Name:
Expiration Date:	Month Year
OTHER INFORMATION
Have you studied at CPC before*?		Yes No
Are you transferring from another school?		Yes No
If yes, School Name:		Location:
Are you registering through an authorized CPC agent?		Yes No
If yes, Agent:		Location:
How did you learn about CPC?	Advertisement Friend	Website Agent	Others
Please specify name, i.e. CPC website, friend’s name, etc.
MEDICAL INSURANCE
I agree that I will purchase medical insurance prior to starting any CPC program and will cover all medical expenses or reimbursements during the program. Initial*:
CONDITIONS OF ENROLLMENT AND REFUND POLICY
I have read and agree to be bound by the “Requirements for Admission” described on page 6 of the CPC Catalogue and the “Refund and Cancellation Policy”. Initial*:
I confirm that my deposit of $500US (toward payment of tuition and school fees) will be made to confirm my registration . Initial*:
“Requirements for Admission”		Cancellation and Refund policy
SIGNATURE
I certify that the information provided on this application form is correct. I have read and understand the “Requirements for Admission” and the Cancellation and Refund policy. By signing this agreement, I authorize CPC to credit my account if the enrollment deposit is greater than my initial tuition and fees. I understand that CPC has the right to change policies, prices, and programs without prior warning. All information on this from is true and accurate to the best of my knowledge. This contract is legal and biding.
Signature of applicant*:		Date*:

“Requirements for Admission”		Cancellation and Refund policy

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