Application Form


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Application Form Please print in BLOCK LETTERS Personal details

Education details

Name must appear exactly as it is in the applicant’s passport.

Have you taken the:

Title:

Mr

Ms

Other

Gender:

Male

Female

GRE:

Yes

If yes, on which date? DAY / MONTH / YEAR

No

Family name:

Your score:

Given names:

If ‘yes’, was your score reported to WKU?

Preferred name:

GMAT:

Date of birth: DAY / MONTH / YEAR

Yes

Yes

No

If yes, on which date? DAY / MONTH / YEAR

No

Your score:

Contact details

If ‘yes’, was your score reported to WKU?

Applicant’s home country address (not recruiter’s address):

TOEFL:

Yes

Yes

No

If yes, on which date? DAY / MONTH / YEAR

No

Your score: If ‘yes’, was your score reported to WKU? Applicant’s mail address in the USA, if applicable (not recruiter’s address):

Yes

English proficiency IELTS score:

City:

State:

No

Zip code:

TOEFL score:

Other:

Mobile telephone:

Are you currently enrolled in an English language school?

Home telephone:

Yes

No

If ‘yes’, name of school:

Applicant’s email: (mandatory):

Current level of English:

Parent/guardian’s email:

Secondary education: highest level achieved

Recruiter’s email: (if applicable):

Name of qualification (eg A-levels):

Nationality/Citizenship School attended:

Country of birth:

Yes

No

City of birth:

Completed:

Country of citizenship:

If ‘no’, when do you expect to complete this qualification? DAY / MONTH / YEAR Country/state:

Ethnic Origin (optional — for statistical purposes only) Do you consider yourself to be Hispanic/Latino?

Yes

Language of instruction:

No

Please attach certified copies of all academic transcripts or mark sheets.

In addition, select one or more of the following racial categories to describe yourself: American Indian or Alaska Native

Asian

Black or African American

White

Native Hawaiian or Pacific Islander

Do not wish to report

Post-secondary and further education Name of qualification: Institution attended: Dates attended:

Program selection: Navitas at WKU

Completed:

Students with a TOEFL score less than 61 or an IELTS overall score less than 4.5 begin their Navitas at WKU studies with our on-campus English as a Second Language Institute (ESLI) partner.

If ‘no’, when do you expect to complete this qualification? DAY / MONTH / YEAR

Are you interested in English courses with ESLI with a pathway to Navitas at WKU? Yes Are you transferring from another U.S. school?

Yes

No

Yes

No

Country/state:

Please attach certified copies of all academic transcripts or mark sheets.

Employment history

Please indicate which program you wish to undertake: UPP: Undergraduate (Students requiring additional language or other academic support will be required to complete up to 12 additional credits depending on their academic level.) Pre-Master’s Program Please indicate the year and semester you wish to begin your studies: Year: August January May Preferred major at WKU (mandatory):

No

Language of instruction:

No

Visa status/type: Have you previously applied for admission to WKU? If ‘yes’, please indicate when:

Yes

If you believe you have relevant employment experience to your chosen degree, please attach details.

Declaration of criminal record Have you ever been convicted of a crime other than a minor traffic violation, or is a criminal charge other than a minor traffic violation pending against you? Yes No If yes, please enclose an explanation with your application. Your application cannot be processed if an explanation is not provided.

Accommodation On-campus residential housing is optional for Navitas at WKU students. If you require on-campus accommodation you must complete a Housing Application form, which is available at wku.edu/housing/files/10housingapp-1.pdf. Please submit the completed form to [email protected] Approved off-campus housing will be arranged for you if you choose not to live on campus. Please indicate your choice for accommodation: On-campus residential housing

Approved off-campus housing

Airport reception Do you require airport pick-up?

Yes

No

Request for learning support If there is anything that may affect your learning (for example, impairments to your mobility, sight, hearing, reading or writing), please notify Navitas at WKU so we can determine our ability to accommodate you. Please indicate your needs on a separate sheet of paper and attach it to this application.

Medical insurance requirements I understand Navitas at WKU will provide a mandatory 12 months of medical coverage upon my arrival in the United States. At the end of 12 months I will be required to extend the initial coverage on a year-by-year basis.

Other information How did you first learn about Navitas at WKU? You may check more than one option: Exhibition/seminar Newspaper/magazine Recommended by an education recruiter Navitas at WKU website

I hereby give Navitas at WKU permission to obtain official records from an educational institution attended by me. I grant Navitas at WKU permission to provide WKU with any information pertaining to my application of study, my ongoing academic progress, my housing, my activities with Student Life at WKU, my results and attendance and other records regarding my studies and activities at Navitas at WKU (collectively, my ‘Student Records’) for the purposes of my admission and transfer to Navitas at WKU and any other educational programs, Navitas program administration and, if I am a minor, or if I have otherwise provided my consent for the use of my Student Records for such purpose, for communicating with my family regarding my status and progress. I understand and agree that WKU may require that I execute a consent or other agreement in order to transfer my Student Records to Navitas at WKU, I hereby agree to promptly execute such consents as may be required in order for WKU to release the above-described Student Records to Navitas at WKU. I understand and agree that Navitas at WKU may collect my personal information and may share it and my Student Records with Navitas Limited and affiliates for the purposes described herein and for the purpose of communicating with you regarding programs and services offered by Navitas Limited and its affiliates. Navitas at WKU, Navitas Limited and affiliates may store my personal information and Student Records in the United States, Hong Kong and Australia and may use my personal information and Student Records for the purposes of administering prospective, current and graduate student admissions and enrollment and education. For further information regarding the data collection and use practices and policies, consult our Privacy Policy located at wku.navitas.com. I understand that after I commence my studies with Navitas at WKU, I will need to successfully complete the program and maintain the minimum required GPA before I can continue my studies at WKU. I understand that if I have applied through an approved WKU or Navitas at WKU recruiter, any information contained in my Navitas at WKU application may be released to that recruiter. I understand that fees may change without notice. I accept liability for payment of all fees as explained in this brochure, and I agree to abide by the Refund Policy, which is current at the time of my studies at Navitas at WKU. I understand that living expenses in the United States may be higher than in my own country and I confirm that I am able to meet these costs. I understand that by signing this application form, I will be eligible to receive a letter of admission from Navitas at WKU.

Applicant’s signature:

Other (please specify below)

Application checklist Check that you have or have attached: Completed all sections of the application form Read and understood the Conditions of Enrollment, including the Refund Policy Certified copies of your academic transcripts Certified evidence of your English language ability, if required A certified copy of your passport or student visa

Date: DAY / MONTH / YEAR If you are under 18 years of age, your parent or guardian must also sign this application form.

Parent’s/guardian’s signature:

Any relevant employment documentation Proof of finances, such as bank statements and affidavit of support

Emergency Please designate a person to be notified in case of emergency

Date: DAY / MONTH / YEAR

Name:

Unsigned applications cannot be processed. Recruiters cannot sign on an applicant’s behalf.

Relationship to applicant:

Postal address for applications

Address:

Navitas at WKU 1906 College Heights Boulevard #81030 Bowling Green, KY 42101-1030 United States of America

Home telephone: Business telephone: Mobile telephone:

Disclaimer (for students aged 18 or older) I grant Navitas at WKU permission to provide my parent(s), guardian(s) and recruiter, when requested, with any information pertaining to my application to study, ongoing academic progress, results and attendance. Yes No

F +1 207 745 3220 E [email protected] W wku.navitas.com

Representative details Representative’s stamp

Please note: This information will be automatically provided to parent(s) or guardian(s) of any student younger than 18 years of age.

Representative name:

Declaration

Address:

Representative Office Code:

Please read this declaration carefully Recruiter’s name: Recruiter’s email address:

Office use only Identification number: Application number:

WKU1804_0714_AW

I declare that all information I have supplied on this form with respect to my application to Navitas at WKU is, to the best of my understanding and belief, complete, accurate and correct. I understand that giving false or incomplete information may lead to the refusal of my application or cancellation of enrollment. I have read and understand the published course information in the brochure or website and I have sufficient information about Navitas at WKU to enroll.