First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Country of citizenship:

Country of birth:

Length of stay:

date of arrival in the US:

date of departure from the US:

Proficiency in English is required. Do you have English language skills adequate to learning detailed and medical information in an English-speaking classroom, without a translator?

Yes     No

The INS requires you to provide documentation of financial resources needed to pay for your course of study and other expenses. Please attach a copy of your financial documentation to this form. You will also need to have such documentation for the visa application process and will need to attach documentation to the form I-20 for your entry into the US.

You will also need to attach a copy of this documentation to the form I-20 for your entry into the US.

The estimated average costs for completion of the 2008 Full-Time massage therapy program:

Please indicate your source of financial means:

Your personal funds: $

Family funds from abroad: $

Funds from another source: $    (specify source):

Will you be bringing with you, or will you be joined by, any dependents?

Yes     No

If you answered Yes, how many dependants will be joining you?

Please keep in mind that you may be asked to demonstrate reasons to return to your home country that are strong enough to "overcome a presumption of intending immigration." Such factors as employment, property ownership, and social ties are normally evaluated as evidence of an applicant's intention to return to the home country.

Please commplete all blanks and return as soon as possible to Jeff Gugino, Finger Lakes School of Massage, 1251 Trumansburg Rd., Ithaca, NY 14850, USA.

Thank you for your cooperation.