IPSA - International Partners for Study Abroad
Application
to College of Travel and English Training
in Hamilton, Canada
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
IPSA Enrollment Center
40240 N. 69th Place
Cave Creek, AZ 85331, USA
or by Fax to: +1 (602) 942-6734
Application Deadlines
Normally, we must receive a complete set of application documents
and fees no later than 30 days before the program starts.
Part A. Personal data:
First Name: ___________________ Last Name: ______________________________
Home Address: _____________________________________________________________
___________________________________________________________________________
Telephone: (____)________________ Fax: [optional] (____)__________________
E-mail: [optional] ________________________________________________________
Date of Birth: (month/day/year) _____/____/___________ __ Male __Female
Place of Birth (country, city): __________________________________________
Nationality: _________________ Citizenship (country): ___________________
SSN (U.S. citizens): _____-___-_______ Native language: __________________
Other languages, if any: __________________________________________________
I am a college __ freshman __ sophomore __ junior __ senior
__ Graduate Student __ High School Senior __ Interested Adult
__ Professional. Please enter your profession: _______________________
If you are a graduate or undergraduate student, please provide the
following information:
Current college/university/graduate school: ______________________________
___________________________________________________________________________
Major field of study: _____________________________________________________
Address of your college, university: ______________________________________
___________________________________________________________________________
Insurance:
It is advisable that students have health insurance while residing or
traveling in the United States. The insurance carrier in the student's home
country can provide this coverage, or short term health coverage through an
Canadian company can be arranged.
My insurance company is: _________________________________________________
Policy Number: ____________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
I want to register for the following program:
__ Intensive Course
__ Business English
__ English plus Golf
__ English plus IT
__ English plus First Aid
__ English plus Internship
__ NGO Volunteering
__ TOEIC Preparation
__ TOEFL Preparation
__ IELTS Preparation
__ Summer Program
__ Travel and Tourism
__ Flight Attendant
__ Hospitality Program
__ Teacher Training - TESOL
__One-to-one private classes.
Please enter the number of lessons a day: _____ and other comments:
__________________________________________________________________________
__________________________________________________________________________
Please enter a number of weeks you want to study: ______ weeks
I have studied English for __years at a ____________________________________
____________________________________________________________________________
(type of school e.g. high school, university, private language school)
What is your present level of English?
__Beginner
__Upper beginner
__Pre-Intermediate
__Lower Intermediate
__Intermediate
__Upper Intermediate
__Pre-Advanced
__Advanced
Accomodations:
Do you require help with accommodations? __ Yes __No
If yes, what type of accomodation would you prefer?
__Host Family - single room, full board
__Host Family - single room, no meals
__Apartment - Shared room with no meals
__Apartment - 1 Bedroom apartment
__Apartment - 2 Bedroom apartment
If you require accommodations other than Host Family, please enter your
requirements:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you smoke? __Yes __No Do you like pets? __Yes __No
Do you like children? __Yes __No
Do you have allergies to food/animals? List: _______________________________
____________________________________________________________________________
Accomodation Arrival date: ________________ Checkout date: ________________
Do you require airport pickup? ___Yes __No
**Arrival date: ____________________________ **Time: _____________________
**Airline _________________________ **Flight Number: _____________________
**Without this information, airport pickup services can not be guaranteed.
Please note that your application will be considered only when your payment of
the enrollment fes and deposits has been received.
A non-refundable application fee of US $80.00, and a tuition deposit of $200.
All payments must be made in U.S. dollars and payable through U.S. banks.
Any collection charges will be the applicant's responsibility. Checks or
international money orders drawn on foreign banks will not be accepted.
Please select one of the following payment options:
1. __Please find enclosed a certified check/money order for the application
fee and the tuition deposit.
Cashiers Checks or international money orders must be made payable to IPSA.
Please send a check or international money order with your application to:
IPSA
40240 N. 69th Place
Cave Creek, AZ 85331, USA
2. International Wire Transfers
You can make your payment by wire transfer. Just fax us your application
and request our account and bank information:
___I want to pay the application fee and the tuition deposit by wire transfer.
Please send me instructions on how to send the wire transfer to your
bank account.
3. Payment by Credit Card:
Please select credit card: ___VISA ___MasterCard
Credit Card No: _____________________ Expiration Date: Month ____ Year_____
Card Verification Value: ___________ (The last three digits on the back of
your credit card after the credit card number.)
Cardholder Name: __________________________________________________________
Street Address: __________________________________________________________
City:______________________ State:___________________ Zip Code:__________
I authorize to charge the above credit card account:
___ application fee and deposit ___ application fee and full payment due
Even if you select a "full payment" option, we will charge the application
fee and the tuition deposit at the time of accepting your application and
will process the payment of the balance to your credit card only after
registering you for the course. Please also note that if you would prefer
to pay the balance by credit card, a 4.5% payment processing service fee
will be included in the invoice.
Comments: _________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Part D. Agreement and release.
By signing this Application, I certify the above information is complete
and correct. I understand that my misrepresentation may result in my
expulsion from the program. I acknowledge that the terms and conditions
appearing on the web site constitute part of my agreement with IPSA and
study abroad program host (university, college, language school, or other
institution and/or organization), including sections concerning
responsibility, health, refunds, changes in dates, accommodations, courses
and billing of selected options; I assume all risks and responsibilities
and discharge IPSA and the study abroad program host and all their officers,
agents and employees from and against any and all claims of damage to
personal property or personal injury which may result from my enrollment
and participation in the study abroad program host courses, excursions, and
/or on and off-campus activities. I have read the Agreement and agree to
follow all IPSA and study abroad host procedures. This Agreement will be
effective when my application is accepted by IPSA and shall be governed by
the laws of the State of Arizona, USA.
Applicant's Signature ______________________ Date: ___________________
Parent's/Legal Gardian's
Signature if applicant
is under 18 years ______________________ Date: __________________
Please do not forget to make a copy of this completed and signed application
for your records and enclose your payment of the application fee and deposits.
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