Application for Admission
Fort Lewis College
Academic English Program
Instructions:
Type all information into the corresponding areas below. Once the form is completed, either:
• Save the file, and email it to:
• Print the form and mail it to:
Yuriko Miller, International Programs Office, Fort Lewis College, 1000 Rim Drive, Durango, CO 81301 USA
Student Residency Information:
Last name First name:
(please enter name exactly as it appears on your passport!)
Middle name:
Date of Birth: / / (mm/dd/yyyy) Age:
Gender: □ Male □ Female
Country of Birth: Country of Citizenship: School Name: School Location: Address to which Admission Information and I-20 should be sent:
Street Number & Name: City: Country: Postal Code: Phone Number: Email:
If you are a permanent resident of the United States, please provide your Alien Registration Number:
Date of Issuance: / / (mm/dd/yyyy)
(Send a photocopy of your visa or both sides of your Permanent Resident Card to the International Programs Office.)
Marital Status: □ Single □ Married □ Widowed □ Divorced Number of Children: You MUST answer the following question. If yes, please include a statement of explanation.
Have you ever been convicted of a crime? (Traffic violations and juvenile offenses are exempt.)
□ Yes □ No
If yes, please explain:
Do you have a physical disability or learning disability?
□ Yes □ No
(This information is voluntary and will not affect the admission decision. It is confidential and intended for use in Colorado collegiate
institutions’ voluntary affirmative efforts to increase participation of persons with disabilities in available programs, activities and services.)
Would you like information about support services for students with disabilities?
□ Yes □ No
Admission Information:
Do you plan to enroll in Fort Lewis College after your summer intensive program?
If yes, please mark the appropriate field below.
Term and Year you expect to enroll at Fort Lewis College (choose only one):
□ Fall Semester
□ Spring Semester
□ Full Academic Year
Major: Have you applied or previously attended Fort Lewis College?
□ No □ Yes If yes, when?
Parental Information:
First Parent/Guardian Information: (select one) □ Parent □ Legal Guardian □ Spouse
First Name: Last Name: Street Number & Name: City: Country: Postal Code: Occupation: Employer: Home Phone Number: Work Phone Number: Email address: Second Parent/Guardian Information: (select one) □ Parent □ Legal Guardian □ Spouse Prefix: First Name: Last Name: Street Number & Name: City: Country: Postal Code: Occupation: Employer: Home Phone Number: Work Phone Number: Email address:
Relatives at Fort Lewis College:
If any relative has attended or is currently attending Fort Lewis College, please list:
Relative #1:
First Name: Last name: Relationship: Years attended: / / to / /
Relative #2:
First Name: Last name: Relationship: Years attended: / / to / /
Application Certification:
By typing my name below, I hereby certify, to the best of my knowledge that the information furnished on this application is true and complete.
I understand that if found otherwise, it is sufficient cause for delay of admission, loss of credit, rejection, or dismissal.
I, hereby, consent to the release of transcript(s) to Fort Lewis College.
Applicant’s Signature (type name): Date: / /
Once this form is completed, either:
• Save the file, and email it to:
• Print the form and mail it to:
Yuriko Miller
International Programs Office
Fort Lewis College, 1000 Rim Drive, Durango, CO 81301 USA
Fort Lewis College does not discriminate on the basis of age, race, color, sexual orientation, religion, national origin, sex, veteran status, or disability in admission or access to, or treatment or employment in, its education programs or activities. Inquiries concerning Title VII, Title IX, Section 504, and Americans with Disabilities Act (ADA), may be referred to the Affirmative Action Director, Fort Lewis College, (970)247-7666 or to the Office for Civil Rights, U.S. Department of Education, 1244 Speer Blvd., Suite 310, Denver, CO 80204, (303)844-5695.