IPSA - International Partners for Study Abroad
Application
to English Language School in Dublin, Ireland
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
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: ______________________________________
___________________________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
I Wish to Book: ___ weeks
Which course would you like to study?
__General English ESL Program with 20 lessons per week
__General English Academic Year ESL 36 weeks Program
__General English Academic Year ESL 25 weeks Program
__General English ESL Program with 10 lessons per week
__Individual (One-to-One) Course
Specialization:
__Business English __ General English __Other:
_____________________________________________________________
_____________________________________________________________
Please check a number of hours of One-to-One instruction per week:
__10 hours __15 hours __20 hours __25 hours __30 hours
Summer courses
__Junior ESL Summer Course (11 - 18 years of age) with accommodation:
__in the Host Family
__in the Residence on University Campus
__no accommodations required
Please select location of the Junior Summer Course Center you want to attend:
__Dublin City University
__Griffis College Dublin
__St. Patrick's College Dublin
__University College Dublin
__Cork Institute Of Technology
__Galway Mayo Institute Of Technology
__Mary Immaculate College in Limirick
__St. Angela's College Sligo
__Tralee Institute of Technology
__Waterford Institute of Technology
For how many weeks do you want to attend ESL Summer Courses: ___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 __Elementary __Low Intermediate __Intermediate __Advanced
Part C. Accomodations.
Do you want us to arrange accommodation for you? __yes __no
If yes, what form of accommodation?
__Homestay, full board:
__Single room __Double room __Ensuite
__Hotel __Hostel __Guest house
Do you smoke? __yes __no
Will you live in a house with children? __yes __no
Will you live in a house with pets? __yes __no
Are there any foods you cannot eat? __yes __no
If yes, please provide details:
___________________________________________________________________________
Do you want us to meet you at the Airport when you arrive? __yes __no
Airline and flight number: _______________________________________________
Arrival date: ______________________________ Arrival time: _______________
Departure city: ____________________________
Part D. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of 75 USD and tuition deposit of $200,
has been received.
In any case, we must receive tuition and accommodation fees due at least 21
days before the commencement of your program.
All payments must be made in U.S. dollars and payable through U.S. banks.
Any collection charges will be the applicant's responsibility. Certified
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 Study
Abroad International 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 the
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 terms and conditions of enrollment 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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