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English Language + Literacy Application
Name
*
First
Last
Birth Date
Month
Day
Year
Address
Street Address
Address Line 2
City
ZIP Code
Email Address
Home Phone
Cell Phone
What is the best way to reach you?
email
home phone
cell phone - call
cell phone - text
What service do you need? (You can check more than one):
*
English Language Class
1-on-1 Tutoring
Check one. I am a:
refugee
asylum seeker
legal permanent resident
immigrant
citizen
other
Where are you from?
*
What is your primary language?
French
Portuguese
Lingala
Kikongo
Tshiluba
Acholi
Spanish
Vietnamese
Chinese (Cantonese)
Chinese (Mandarin)
Somali
Kirundi
Kinyarwanda
Swahili
Thai
When did you arrive in the U.S.A?
Month
Day
Year
When did you arrive in Maine?
Month
Day
Year
Check your answer. In my home language, I can:
read
write
speak
Are you working?
Yes
No
If yes, where?
Choose your answer. In my country I finished…
elementary school
middle school
some high school
high school diploma
some college classes
bachelor’s degree
master’s degree
PhD
professional certificate
I never went to school
What is your English level?
0 - 1 (beginner)
2 - 3 (intermediate)
4 - 5 (advanced)
I don't know
Are you taking classes at another place?
Yes
No
If yes, where?
When are you free to take classes or meet with a tutor?
Morning
Afternoon
Evening
What day of the week are you free to take classes or meet with a tutor?
Monday
Tuesday
Wednesday
Thursday
Friday
How did you find us?
My case worker
A friend
General Assistance
Portland Adult Ed.
Other
Please specify other
Referring Person/Organization
Phone Number
Δ