LYI Student Application Page

Please fill out all fields below. After pushing the submit button please allow 24 hours for processing.

User Information

User Information  
Users First Name
Last Name
Street Address
City
State/ Province
Postal Code
Country
Home Phone No spaces or dashes
Fax No spaces or dashes
E- Mail (This will be used for bills)
Expected date of arrival in Israel
Expected return date
School/ Program Name
Address in Israel
School/ Program Phone Number No spaces or dashes
Number of phones required?
Phone Preference (subject to availability) Motorola i80s    Motorola i90c
You will need to fax a separate  credit card form, how would you like to receive this form?
Fax E mail Download from Confirmation page
How would you like to receive you bill? E mail    Mail  ($2.00 fee for US mail)
How did you hear about us?
Shipping Information  
Shipping Method Standard ($7.50)  Express ($15.00)  Pick Up (Free)
Street Address
City

State/ Province

Postal Code
Country

*By clicking submit, applicant agrees to the Terms and Conditions available upon request or by visiting www.amigo-us.com/termsand.htm

After submitting your application, please complete the credit card form which is available for download from the confirmation page or which will be sent to you as per your request. Forms should be faxed to 718-258-2572

Call 1-888-amigo-us

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