Student Application Nonvisa Application: Non-Student Visa /申込書（記入はアルファベットで） *required field /必須 Personal Information /申込者 First Name* /名 Family Name* /姓 Gender* /性別 Male/男性Female/女性 Date of Birth* /生年月日(例: 月月/日日/年年年年) Country of Citizenship* /国籍(例: Japan) Contact Information /連絡先と住所 Your Email* /メールアドレス Street Address* /番地(例: 3-3-9-604,Kamiosaki) City/Town* /町市区(例: Shinagawa-ku) State* /都道府県(例: Tokyo) Postal/Zip Code* /郵便番号(例: 141-0021) Country* /国(例: Japan) Primary Phone* /電話1(例: 03-5555-0123) Secondary Phone /電話2 Study Information Program*/プログラム English For Communication (EC)English For Business (EB)Teen Summer English Camp/ティーン イングリッシュ キャンプGroup Study TourPrivate Lessons/プライベートレッスンKids English Adventure/キッズ イングリッシュ アドベンチャーOther (please specify desired program in Note/Message section below Start Date* /スタート日(例: 08/01/2016) End Date* /最終日(例: 08/26/2016) Accommodation Information Choice of Accommodations* /滞在先手配 Homestay (airport pick up required)/ホームステイIsland Colony Studio (airport pick up required)Island Colony One Bedroom (airport pick up required)EWA Suite StudioNo Accommodation Required/滞在先手配はいりません Accommodation Start Date* /滞在先チェックイン (weekend before class start date is recommended) Accommodation End Date*/滞在先チェックアウト (weekend after class end date is recommended) Do you require an airport transfer? ($130 round-trip airport transfer is mandatory for homestay) $75 Pick up with traditional lei greeting$55 Drop off at airport Notes or Messages? Your Message /コメント Payment /支払い Application Fees: /登録料$175 $175 Registration Fee: required for all applications to ICC$180 Accommodation Placement Fee: required for students who reserve accommodations with ICC/滞在先手配料＄180 If you need your I-20 form in 3-5 days, ICC can send it 1express. If not sent by express mail, you should receive your I-20 form by standard mail in 1-4 weeks Tuition Full payment of tuition or payment of first 12 weeks (if studying longer) is due 30 days before the student's first day of classes If registering 30 days or less before first day of class, full payment is due upon registration confirmation How will you pay application fee(s)?* /支払い方法 Cash (in person only)/現金Check (U.S. banks only)/小切手Traveler’s Check (in person only)/トラベラーズチェックMoney Order or International Bank Draft/為替・郵便為替Wire transfer (contact ICC for payment instructions)/海外送金Pay Pal Credit Card/クレジットカード (in person, via phone, or with authorization form) (Visa, MasterCard, American Express, Dinners, JCB, and UnionPay) Terms & Conditions: In order to submit your application, you must pay the $175 registration fee by PayPal, credit card, cash, check, or wire transfer. After the receipt of your online application, you will receive an email from Intercultural College within three business days with a confirmation of your application. If you are applying for a student visa, you will be required to pay the $250 SEVIS fee (Optional $100 express mail fee). If you are applying for accommodations, you are required to pay the $180 Accommodation Placement Fee. The Registration Fee, SEVIS Fee, SEVIS shipping cost and Accommodation Placement Fee are nonrefundable. Full payment is due 30 days before the student's first day of study. If registering 30 days or less before first day of class, full payment is due upon registration confirmation. ICC accepts PayPal, cash, check, credit card, or wire transfer. Please make checks payable to Intercultural Communications College. The payee is responsible for all wire transfer fees. For more information, please contact our registrar at firstname.lastname@example.org. *I agree to the terms and conditions above and have read and understand ICC tuition and accommodation cancellation policies.