Contact Us
1. PRINCIPAL(S), DÉCIDEURS ET ADMINISTRATEUR(S) DE L'ÉDUCATION
For education administrators in elementary, secondary, higher and vocational institutions interested by our innovating training and schools/educational management programs, contact us by explaining briefly below your needs in teachers training or the reorganization of your institution.
First-Last Name
 :
E-mail
 :
Phone
 :
Comments :
2. STUDENTS, RESEARCHERS, SCHOLARS AND OTHER PROFESSIONALS
Students planning to study in the USA, read CAREFULLY, and complete ENTIRELY the form below to benefit from our services.
EVALUATION FORM
****If a section does not apply to you, type in the space of that section "n/a" (non-applicable). ****
SECTION A
PERSONAL INFORMATION
1 Name Surname(s)
 
2 Sexe 3 Date of birth (year-month-day) 4 Place of birth
   
 
Country City
5 Nationality 6 Country of residence
   
7 Telephone (+ country code) 8 Current Adress
   
Country City
 
SECTION B
DETAIL OF PLAN OF STUDY IN THE USA
1 School Name (if have already made a choice) Date (tentative) of your arrival in the USA
 
2 Program(s) of study 3 Lenght of study
   
From (year-month-day) To (year-month-day)
4 Possible cost of studies
 
Tuition and Fees Homestay ( campus residence or apt) Tuition and fess paid by :
 
SECTION C
EDUCATION
1 School Diploma/Degree Dates
From (year-month-day)- To (year-month-day)
 
To
 
To
 
To
 
SECTION D
ENGLISH LEVEL
Advanced Intermediate Average Elementary Novice
What English Language Test(s) Test(s) you already took or planning to take ?
TOEL IELTS GMAT GRE Other
 
SECTION E
EMPLOYMENT
(If your are working, please complete this part by starting by your current or recent job)
1 Job Title Employer Dates
From (year-month-day) - To (year-month-day)
 
To
 
To
 
SECTION F
If you have additional comments use the space below
 
SECTION G
SIGNATURE
I confirm that the particulars given in this form are to the best of my knowledge and belief correct; and I understand that this information is necessary for an initial evaluation of my application in order to plan the process of my admission in an academic institution in the USA. I also understand that the fees related to this initial evaluation are non-refundable, and that after having received the results of this evaluation, I will have the choice to continue (or not) the process until my full admission in an academic institution in the USA.
Your Signature or the Legal Guardian and/or Parent
Click signer
Date (year-month-day)
 
 
SECTION H
METHOD OF PAYMENT
This application can only be validated if it is accompanied by the fee below:

35.000 FCFA (≈ 80 U.S $)
 
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© International Center for Leadership in Education, INC.