Master Application Form

If you would like to apply at Conversa, please fill out the Application Form below and submit, fax or mail it to us.

Application Form

Last Name:

First Name:

Middle Initial:

Street Address:		City:
Postal Code:		Country:
Country of Birth:		Country of Citizenship:
Telephone Number		Fax Number

E-mail Address:

Date of Birth (Month/Day/Year):
How many years have you studied English?

Which type of housing do you prefer? Please choose one of the following:

Do you have health insurance that is valid in the United States?: YES NO If yes, please provide a copy of the policy in your application.

When do you plan to begin studying at Conversa?:
How many months do you want to study?:

Please write any additional comments here:

Q.1 - Do you smoke?	YES No
Q.2 - Do you mind if other people in the house smoke?	YES NO
Q.3 - Do you drink alcoholic beverages?	YES NO
Q.4 - Do you need handicap facilities?	YES NO
Q.5 - Do you have any allergies to food, pets or medicine?	YES NO

Financial Certification for I-20 Form

If you need an I-20 form to get a student visa you must provide certification that you, your parents, or legal guardian are able to cover the cost of your tuition and living expenses. Any one of the following is acceptable as a means of guaranteeing sufficient funds:

A current personal bank statement or a letter from your bank
A letter of support from your parents and a bank statement (or a bank letter) from your parents, or legal guardian, indicating financial support.
A letter from your employer or other sponsoring agent guaranteeing their financial support
An original letter of scholarship from your sponsorship government of organization

I understand my financial obligation to Conversa and accept responsibility for payment thereof. In case of illness and/or emergency, I give my permission to any appropriate medical center to examine and/or treat me and to make any necessary recommendations to outside physicians. I also grant permission to release information regarding the applicant's health to appropriate individuals. I also authorize Conversa Language Center to release information regarding studies to the applicant's sponsoring agency, parents, or legal guardians, whose signature appears below. Conversa will do everything possible to make its students stay here safe and enjoyable. However, Conversa takes no responsibility for personal injury or loss or damage to personal property while living and studying at Conversa. The application form will not be processed without the application fee.

Signature of Applicant:		Date:
Signature of Applicant's Guardian:		Date:

(if applicant is under 21)

If you prefer, you may print this form and fax or mail it to us.

Please fill-out application and return to:

Conversa Language Center
817 Main Street, 6th Floor
Cincinnati, Ohio 45202
Tel: 513-651-5679
Fax: 513-665-3792


	For more information, please E-mail us. To contact us by mail or fax, please click Conversa Language Center.