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Personal Information

Male Female

U.S. Address (If you are in the U.S. or know where in the U.S. you will reside):

Foreign Address (The place you reside when you are not in the U.S.)

Mailing Address (The address to which you wish your acceptance package to be delivered.)

Same as US Address

Same as Foreign Address

Location/ Program Information

Which Center?:

Irvine Los Angeles Pasadena

Which Term Will You Start (Select ONE)?

which program

How Many 4-Week Terms (2-12)?:

Airport Transfer Service($80)

Would you like POLY to arrange airport pick-up upon your arrival?

Yes No

For U.S.California Resident(Strf Assessment Fee)

A California resident, required by BPPE, must provide social security number and pay the STRF assessment fee.

Are you a California resident?

Yes No

if yes social security number:

For F-1 Visa Student

Do you need the Form I-20?

Yes No

Do you have dependents you wish to add on your Form I-20?

Yes No

Dependent Information (State your spouse, son, and/or daughter you want to add in the Form I-20.)

Dependent1:

Dependent2:

Dependent3:

Dependent4:

Accommodation Arrangement Service($200)

Would you like POLY to arrange your housing?

Yes No

If yes, complete below.

From:

To:

Type of Housing Preferred
Student Residence: Single Student Residence: Double Homestay: With Meals Homestay: Without Meals
Do you smoke (smoking is allowed only in the designated areas)?
Yes No
Do you have any health problems, allergies, or concerns you would like us to know?

Emergency Contact

In case of an emergency, state below the person you wish us to contact.

Payment

Select applicable fees due with this application.

F-1 Students		$150.00
All Other Students		$100.00
Acceptance Packet (Must select one) * Express Mail (Outside the U.S.) Express Mail (Within the U.S.) Pick-up in Person		$65.00 $30.00 $0.00
Total Fee Due with this Application:

Payment Method

* AMEX Mastercard Visa Discover

Acknowledgement

* I certify that I have received the School Catalog, and I have read, understood, and I agree to all the terms and conditions of this Application for Admission form and the School Catalog. Furthermore, I agree to accept full responsibility for all my expenses while attending POLY and for my actions while participating in excursions or any other activities. I agree to assume all risks of harm arising from such participations. In case of illness or injury, permission is granted to an appropriate medical center to undergo examination or treatment. I further authorize POLY to release my records to my agency, guardian, sponsor, and to any colleges or universities to which I apply.

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04/24/2025