Africa Institute Seattle

Africa Institute Seattle
4414 212 St SW Suite #F10
Mountlake Terrace, WA 98043, USA

REGISTRATION/ADMISSION FORM

Last Name (Surnames) Used (Maiden, Religious, Professional, Aliases)
First and Middle Names (As in Passport)
Other Surnames Used (Maiden, Religious, Professional, Aliases)
Home Address (Include apartment number, street, city, state or province, postal zone and country)Street Address Line 1
Street Address Line 2
Date of Birth (month-dd-yyyy)
Date
Month
Year
Place of Birth
City:
State:
Country:
Gender
Sex
Male
Female
Marital Status
Married    Single (Never Married)
Widowed Divorced Separated
Phone/Fax Numbers

Home Phone
Home Fax

Business/Office Phone
Business/Office Fax

Cell/Mobile Phone
Pagers
Email:
Education:
Name of Present School
Name:
Address of Present/Past Schools
Address:
Employment:
Name of Present Employer
Name:
Address of Present/Past Employer
Address:
IMPORTANT: CHECK THE APPROPRIATE BOX FOR EACH ITEM:
ALL APPLICANTS MUST READ.
Have you ever been arrested or convicted for any offense or crime, even if you have been granted a pardon? Have you ever been a prostitute or procurer for prostitutes?
Yes No
Do you need any accommodation as a result of disability?
Yes No
Do you have a valid Visa to the U.S. or are you lawful permanent resident in the United States?
Yes No
Are you a U.S or a U.S. Permanent Resident?
If your answer is Yes, you would be asked to show a proof
Yes No
Drivers License # & State of Issuance:
D/L #:

FOR FOREIGN/INTERNATIONAL STUDENTS
Passport #:
Date of Issuance of Passport (month-dd-yyyy)
Date
Month
Year
Place of Issuance of Passport
City:
State/Province:
Country:
Nationality:
Country:
When Do You Intend To Arrive In The U.S.?
(Provide specific date if known) -Foreign Students only
Date
Month
Year

At What Address Will You Stay in The U.S.? Foreign Students Only
Street Address Line 1
Street Address Line 2
City:
State/Province:
Country:
Visa Information
Do You Attest to Leave the U.S. at the end of your studies. Statement is required?
If need be on a separate sheet of paper
What Type of Visa do you have?
Who Will Pay For Your Studies?

Have You Ever Been in The U.S.?Yes No
When (month-dd-yyyy)
Date
Month
Year
Length of Stay
How long?
When do you intend to arrive the U.S.? (Please do not leave without a student visa)
(Provide specific date if known) -Foreign Students Only
Date:
Month:
Year:
Name, Address, Phone of Your Next of Kin (for International Student only) in the U.S.

Last Name (Surnames) Used (Maiden, Religious, Professional, Aliases)
First and Middle Names (As in Passport)
Other Surnames Used (Maiden, Religious, Professional, Aliases)
Home Address (Include apartment number, street, city, state, zip code)
Street Address Line 1
Street Address Line 2
City:
State:
Home Phone
Home Fax
Business Phone
Cell Phone
What Type of Visa do you have?
Did You Graduate from High School? Yes No
WHEN?
Date
Month
Year
WHAT TYPE OF VISA DO YOU HAVE?
Have You Ever Been Refused admissions anywhere or in the U.S. before?
Yes No
When?
Date
Month
Year
Which Country?

Has Anyone Ever Filed an Immigrant Visa Petition on Your Behalf?
Yes No If Yes, Who?
Last Name (Surnames) Used (Maiden, Religious, Professional, Aliases)
First and Middle Names (As in Passport)
Home Address (Include apartment number, street, city, state, zip code)
Street Address Line 1
Street Address Line 2
City:
State:
Country:
Has your admission ever been revoked? Yes No
Names and Relationships of Persons Traveling With You
Are Any of The Following Persons in The U.S., or Do They Have U.S. Legal Permanent Residence or U.S. Citizenship? Mark YES or NO & indicate that person's status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, visiting, studying, working, etc?.
Yes No
Husband/Wife
Yes No
Father/Mother
Yes No
Fiancé Fiancée
Yes No
Son/Daughter

Yes No
Brother/Sister
IMPORTANT
Have you ever been arrested or convicted for any offense or crime, even if you have been granted a pardon?
Yes No

ATTESTATION:
Did Another Person on Your Behalf prepare this Application?
Yes No (If answer is YES, then have that person sign his name after yours.)

Application Prepared by
Last Name (Surnames) Used (Maiden, Religious, Professional, Aliases)
First and Middle Names (As in Passport)
Home Address (Include apartment number, street, city, state, zip code)
Street Address Line 1
City:
State:
Country
Relationship to Applicant:
Signature of Person Preparing Form:

DATE (month-dd-yyyy)
Date
Month
Year
Attestation:
Do You Attest to Leave the U.S. at the end of your studies Statement is required?
I certify that this application is completed truthfully to the best of my knowledge. In fact, all information hereby furnished in this application form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in dismissal from the Africa Institute and/or permanent refusal or denial for admission into any academic program of AI: African Institute. I truly know and now understand that possession of an admission acceptance does not automatically entitle the bearer to disobey the policies of Africa Institute Seattle and the laws of the United States of America. Consequently, if found disobeying the laws of the U.S. or the policies of this college, Africa Institute Seattle, the student's admission may be revoked..

Date
Month
Year
Signature:


_You can complete & cut out this form before mailing to:__
The Registrar
Africa Institute Seattle
4414 212 St SW Suite #F10
Mountlake Terrace, WA 98043, USA