Student Information Form

Please complete the fields below.                  * Indicates required field.

*First Name:
*Last Name:
*Date of Birth (mm/dd/yyyy):
*Gender:
*Program:
*Ticketing Process:
Contact Information

*Preferred Email Address:
*Daytime Phone:
Evening Phone:
Permanent Address

*Country:
*Address Street 1:
Address Street 2:
*City:
State (if USA):
*Zip Code: (5 digits)
Passport Information If you do not currently have a passport, please apply for one and provide the passport information as soon as possible.
*Citizenship (Country):
*Address Street 1:
Address Street 2:
*City:
State (if USA):
Country Passport Issued By:
Passport Number:
Expiration Date (mm/dd/yyyy):
Emergency Contact
*Name:
*Relationship:
*Email Address:
*Country of Residence:
*Home Phone Number (include country code):
Cell Phone Number:
Applicant Signature I declare that:
    The above information and the documents included in my application are accurate and correct to the best of my knowledge.
    I agree to abide by the laws of the People's Republic of China and agree not to engage in any illegal activities during my academic pursuits in China.
  I have read and I accept The Chinese Language Institute’s Terms and Conditions.
Electronic Signature of Applicant: I agree with all declarations stated above.

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