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Application Instructions **Applicants must be 18 years old OR have completed secondary school prior to enrollment
The following forms and documents are required for admission to Leeward Community College (Leeward CC)
Checklist for applicants who are on non-immigrant visa
(e.g. J-1/J-2, A-2, H-4, and K-1)
Checklist for ELI applicants who are U.S. citizen or permanent resident
Academic Calendar & Recommended Application Submission Dates
Credit Program ELI Program
Note: All submitted forms and documents become the
property of Leeward Community College Office of
International Programs and cannot be returned.
Forms and documents
✓
A. International Student Application Form. Complete in full; then sign & date.
B. US$100.00 Non-refundable Application Fee Payable to Leeward Community College.
C. Copy of Passport and Visa pages.
D. Form I-94. (Please retrieve your I-94 from https://i94.cbp.dhs.gov/I94/#/home#section )
E. Form DS-2019. (ONLY for J-1/J-2 visa holder.)
F. If you are not the primary visa holder, please submit:
• Copy of your primary visa holder’s Passport and Visa pages.
• Copy of your primary visa holder’s Form I-94.
• Copy of your primary visa holder’s DS-2019 (ONLY for J status applicant.)
Forms and documents
✓
A. International Student Application Form. Complete in full; then sign & date.
B. US$100.00 Non-refundable Application Fee Payable to Leeward Community College.
C. Copy of U.S. Passport or Permanent Resident Card.
Office of International Programs
96-045 Ala Ike
Pearl City, HI 96782
Phone: (808) 455-0570
Fax: (808) 455-0568
http://www.leeward.hawaii.edu/ipo
Non-F-1 Student Application Checklist
1. This application is for (please select ONLY one):
English Language Institute (ELI): ☐ Summer 2020 (Jun 15 – Aug 7) ☐ Fall-I 2020 (Aug 24 – Oct 16)
☐ Fall-II 2020 (Oct 19 – Dec 11) ☐ Spring-I 2021 (Jan 11 – Mar 5)
☐ Spring-II 2021 (Mar 8 – May 7) ☐ Summer 2021 (Jun 14 – Aug 6)
Credit Program (undergraduate degree/certificate):
☐ Summer sessions 2020 (Summer session: May 26 – Aug 14) *Divided into Session I & Session II
☐ Fall semester 2020 (Aug 24 – Dec 18) ☐ Spring semester 2021 (Jan 11 – May 14)
☐ Summer sessions 2021 (Summer session: May 24 – Aug 13) *Divided into Session I & Session II
*An official English proficiency test score is required to apply directly to the credit program.
(TOEFL: 61 on iBT or 500 paper test / IELTS: 5.5 / Step Eiken: 2A / GTEC 1051)
Educational Goal (select one): ☐ Associate Degree ☐ Transfer to a 4-year university ☐ Certificate Only
Academic Major at Leeward Community College: _____________________________ (*Must select one from the list.)
2. Student Enrollment Status:
☐ Initial Student – Applying from outside the United States
☐ Transfer Student – Transferring from another language school, college, or university in the United States
☐ Returning Student – Returning to Leeward Community College after an absence
3. Full legal name: _____________________________ __________________________ ___________________
LAST (FAMILY NAME) FIRST (GIVEN NAME) MIDDLE NAME
4. Date of Birth: _______/_______/_______ Gender: ☐ Male ☐ Female
Month Day Year
5. Country of Birth: _______________ Country of Citizenship: ________________ City of Birth: ______________
6. Permanent address in home country: _____________________________________________________________
___________________________________________________________________________________________
City Prefecture/Province Postal Code Country
7. Address in U.S. (if applicable) or Mailing Address: _________________________________________________
Street
____________________________________________________________________________________________________________________________
Apt/Unit # City State Zip Code
8. Telephone Number: __________________________ E-mail Address: _________________________________
Office of International Programs
96-045 Ala Ike
Pearl City, HI 96782
Phone: (808) 455-0570
Fax: (808) 455-0568
http://www.leeward.hawaii.edu/ipo
International Student Application Form
APPLICATION TYPE & PROGRAM INFORMATION
If you are returning to Leeward Community College or transferring from
another University of Hawai'i campus, please provide your UH Student
ID number.
□□□□-□□□□
PERSONAL INFORMATION
9. List every school including high school, college, university and language program that you have attended or are
currently attending:
High School
Country
From (Month/Year)
To (Month/Year)
Graduated
☐ Yes
☐ No
College/University/
Language Program
Country
From (Month/Year)
To (Month/Year)
Graduated
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Please complete the following if you are currently in the United States:
10. Date of Entry into the United States: _______/_______/_______ Type of Visa at Entry: ___________________
Month Day Year
11. Your Current Immigration Status: _________ Expiration Date of I-94 card (if not on F-1 visa): ______________
12. Do you plan to travel outside the United States BEFORE the beginning of the term? ☐ Yes ☐ No
13. Do you have a dependent spouse and/or child who will accompany you? ☐ Yes ☐ No
If yes, please provide their information below and submit their copies of their passport.
Full legal name: _____________________________ __________________________ ___________________
LAST (FAMILY NAME) FIRST (GIVEN NAME) MIDDLE NAME
Date of Birth: _______/_______/_______ Gender: ☐ Male ☐ Female Relationship: ☐ Spouse ☐ Child
Month Day Year
Full legal name: _____________________________ __________________________ ___________________
LAST (FAMILY NAME) FIRST (GIVEN NAME) MIDDLE NAME
Date of Birth: _______/_______/_______ Gender: ☐ Male ☐ Female Relationship: ☐ Spouse ☐ Child
Month Day Year
I certify that the answers and responses provided for all of the items on the University of Hawai'i – Leeward Community
College International Student Application Form are complete and true to the best of my knowledge and belief. I
understand that providing incomplete, incorrect, or false information may result in the rescission or denial of my
admission. If accepted to Leeward Community College, I hereby agree to abide by all the rules and regulations set forth
by the College including purchasing mandatory group health insurance plan.
Signature: _____________________________________________ Date: _______/_______/_______
Month Day Year
VISA & IMMIGRATION INFORMATION
EDUCATION
APPLICATION’S SIGNATURE & CERTIFICATION
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| Last updated by AHJ: 04/09/2020
CREDIT CARD PAYMENT FORM
If you wish to pay your application fee and/or shipping fee by credit, please complete
this form clearly.
* MasterCard, VISA, or Discover credit card ONLY
To pay by check, money order, or cashier’s check, please include two separate payments
(1. Application Fee & 2. FedEx Delivery Fee)
Student Name: __________________________________________________________
Family/Last/Surname Given/First
Name on Credit Card: ____________________________________________________
Credit Card Number: _____________________________________________________
Exp. Date: _________________ 3-Digit Security Code: ________
Cardholder Billing Address: _______________________________
Number Street Apt/Unit #
_______________________________________________________
City Province Country Postal Code
Cardholder’s Name (Print): ________________________________________
Cardholder’s Signature: __________________________ Date: ___________________
This payment is for: Please ✔ appropriate item(s)
English Language Institute (ELI) Application Fee
US$100.00
Degree Program Application Fee (Certificate/Associate degree programs)
US$25.00
FedEx Deliver Fee (REQUIRED for overseas applicants):
US$40.00
TOTAL AMOUNT (Please specify)
Office of International Programs
96-045 Ala Ike
Pearl City, HI 96782
Phone: (808) 455-0570
Fax: (808) 455-0568
http://www.leeward.hawaii.edu/ipo
OFFICE USE ONLY
Student’s UH ID#: ________________________ Application Term: ____________________________
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Completed 3 February 2021

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