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

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)

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

Select a Program* プログラムを下記よりお選びください
English For Communication (EC)Cambridge Exam Preparation FCE (12 weeks)Cambridge Exam Preparation CAE (12 weeks)Cambridge Exam Preparation CPE (12 weeks)Cambridge Exam Preparation - Intensive - FCE (9 weeks)Cambridge Exam Preparation - Intensive - CAE (9 weeks)Cambridge Exam Preparation - Intensive - CPE (9 weeks)CELTA Teacher Training CoursePrivate Lessons

Select a Program* プログラムを下記よりお選びください
Teens & Kids Winter English: Program Only /冬 英語クラスのみTeens & Kids Winter English: Program + Activities ／冬 英語＋アクティビティTeens & Kids Spring English: Program Only /春 英語クラスのみTeens & Kids Spring English: Program + Activities ／春 英語＋アクティビティTeens & Kids Summer English: Program Only /夏 英語クラスのみTeens & Kids Summer English: Program + Activities /夏 英語＋アクティビティ

Select a Level* /英語レベル
Beginner／初級Intermediate／中級Advanced／上級

Start Date* /スタート日(例: 08/01/2016)

End Date* /最終日(例: 08/26/2016)

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)
$85 Pick up with traditional lei greeting$55 Drop off at airport

Your Message /コメント

• Full payment of tuition or payment of first 12 weeks (if studying longer) is due 15 days before the student's first day of classes. 12週間以上の滞在の場合、最初の12週分の授業料を授業開始日の15日前までに支払う。
• If registering 30 days or less before first day of class, full payment is due upon registration confirmation. 授業開始日より30日前以降のお申込みの場合、お申し込みを以って全額を支払う。
• Email registrar@icchawaii.edu for payment. お支払いは registrar@icchawaii.edu まで。

How will you pay application fee(s)?* /支払い方法
Cash (in person only) 現金（現地支払いのみ）Check (U.S. banks only) 小切手（アメリカの銀行のもののみ）Traveler’s Check (in person only) トラベラーズチェック（現地支払いのみ）Money Order or International Bank Draft (郵便為替又は銀行手形)Wire transfer (contact ICC for payment instructions) 銀行送金（支払先情報はお問合せ下さい）Pay Pal or Credit Card (Pay Pal又はクレジットカード)

(in person, via phone, or with authorization form) （直接、お電話又は専用フォームにて）
(Visa, MasterCard, American Express, Dinners, JCB, and UnionPay)

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 accommodations, you are required to pay the $195 Accommodation Placement Fee. The Registration Fee 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 registrar@icchawaii.edu.

*I agree to the terms and conditions above and have read and understand ICC tuition and accommodation cancellation policies.上記のterms and conditionsを読み、ICCの授業料及び滞在費のキャンセル規定を読み、理解しました。