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Application Form

* Required

Your Personal Information

Last Name * First Name *
Male or Female * Date of birth * MM/DD/YYYY
Nationality * E-mail *
Current Address *
Tel * Fax

Emergency Contact in Home Country (or US)

Name * Relationship *
Phone * Email
Address *

Visa Information

Visa *

Course Information

Course *
Starting Date * MM/DD/YYYY Course Weeks *
*You can start HIA program every Monday except for holidays.

Accommodation Request

Accommodation *
Check-in Date * MM/DD/YYYY Check-out Date * MM/DD/YYYY

*If you chose homestay, please answer the questions below,
Hobbies Smoke
Allergies: food Allergies: pet
Other Request

Optional Services

Airport Pick-up * Pick up Drop off None *San Diego Intl Airport Only
Flight Information:
Arrival Date MM/DD/YYYY Time
Airline Flight Number
Departure Place

Payment Information

Payment Method *
*If you chose Credit Card, please answer the questions below,
Type of Card
Card Number Expiration Date /
Credit Card ID
(last 3digits on back of card)		 Name of card holder

Please submit the $120 non refundable Registration Fee with your form.