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English Language + Literacy Application
Name
*
First
Last
Birth Date
MM
DD
YYYY
Address
Street Address
Address Line 2
City
ZIP Code
Email
Phone
What service do you need? (You can check more than one)
*
English Language Class
Literacy
Employment Readiness
1 to 1 Tutoring
Check one. I am a
refugee
asylum seeker
immigrant
citizen
Where are you from?
*
When did you arrive in the U.S.A?
MM
DD
YYYY
When did you arrive in Maine?
MM
DD
YYYY
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
2
3
4
5
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
Email
For questions or to make or speak about a referral, contact the English Language and Literacy program at (207) 775-0105 ext. 165 or fax (207) 775-1932