IPSA - International Partners for Study Abroad
Application
to Italian Language and Art Institute in Florence
Italian Language and Supplementary courses
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 your application and a full payment
no later than 40 days before the program starts.
Part A. Personal data:
First Name: ___________________ Last Name: ______________________________
Home Address: _____________________________________________________________
___________________________________________________________________________
Telephone: (____)________________ Fax: [optional] (____)__________________
E-mail: __________________________________________________________________
Date of Birth: (month/day/year) _____/____/___________ __ Male __Female
Place of Birth (country, city): __________________________________________
Nationality: _________________ Citizenship (country): ___________________
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 occupation: _______________________
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?
Group and Combination Courses:
__Espresso 4 __Espresso 2 __Regular Italian __Combo __Suplementary Course
Individual courses:
__I1 __I2 __I2 plus __I3 __I3 plus __Language, Art and Culture
certification courses:
__CILS/CELI 3 __CILS/CELI 4
I have studied Italian for __Years at a ____________________________________
(type of school e.g. high school, university, private language school)
What is your present level of Italian?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Accomodations:
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
First Choice Second Choice
Family, single room with breakfast ___ ___
Family, double room with breakfast ___ ___
Family, single room with half board ___ ___
Family, double room with half board ___ ___
Apartment, single room ___ ___
Apartment, double room ___ ___
Please check two choices. Accommodation Reservation is subject to space
availability.
Do you smoke? __Yes __No
Do you have allergies to food/animals? List: _______________________________
____________________________________________________________________________
Accommodation will be arranged subject to availability.
Accomodation Arrival date: ___________________________
Checkout date: _______________________________________
Part C. Payment of Fees:
A non-refundable application fee of US$75 and a tuition deposit of US$200
are required with your application. If you apply less than 30 days before
the program starts, please also send a last minute bookings supplement of
US$60.00. The above fees and deposit are part of the cost of your program
and are deducted from the total of the program fees after conversion them in
Euro according to the current exchange rate for buyers. Please note that
your application will be considered only when your payment of the
application fee and the tuition deposit has been received.
Upon receiving your application and your payment of the required fee(s) and
the tuition deposit, we will send you registration confirmation and invoice
for the balance due. The balance may be paid in Euro or in U.S. Dollars.
Please note that normally we must receive a full payment of the program fees
at least 40 days before the commencement of your program.
Payments of the application fee and deposit 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 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 all terms and conditiones and
rules and agree to follow all IPSA and study abroad host procedures and
regulations. This Agreement will be effective when my application is
accepted by IPSA and shall be governed by the laws of the State of Arizona.
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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