IPSA - International Partners for Study Abroad
Application
to English Language School in Valletta, Malta.
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 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): ___________________
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) _____________ (Mo) ______(Year)
For how many weeks do you want to register: ____Number of weeks
Which course would you like to study?
Please check one of the following courses:
__General English Holiday Program (4 lessons per day)
__General English Intensive Program (4 lessons per day)
__General English Intensive Program (6 lessons per day)
__Business English Semi-Intensive (4 lessons per day)
__Executive English Intensive (6 lessons per day in small group)
__Executive English Intensive One-to-one course:
___25 lessons per week ___35 lessons per week ___45 lessons per week
__Preparation Courses leading to exam (4 lessons per day)
__Preparation Courses leading to exam (6 lessons per day)
please enter the name of the exam below:
________________________________________________________________________
__Private one-to-one General English lessons: ___lessons per week
__Semi-Private two-to-one General English: ___lessons per week
(for 2 students arriving and enrolling together)
__Private course for specialised purposes: ___lessons per week
__Combination 20 group + 5 one-to-one lessons per week
__Combination 20 group + 10 one-to-one lessons per week
__Young Learner Summer Program
What is your present level of English?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Accomodations:
Do you need our help with accommodations? __yes __no
If yes, would you prefer to stay in a host family/hotel etc. in Valletta
itself or in a nearby seaside location (15 minute bus journey)
__yes __no
Please select the accommodation option you prefer:
__Host family accommodation:
__single room, breakfast and dinner __single room, breakfast only
__shared room, breakfast and dinner __shared room, breakfast only
__Self-catering accommodations
__Hotel: __2 Star __3 Star __4 Star __5 Star
Please also fill in below:
Are you a smoker? __yes __no
If you have a special diet, please specify:
___________________________________________________________________________
If you have allergies, please specify:
___________________________________________________________________________
If you have other requirements, please specify:
___________________________________________________________________________
___________________________________________________________________________
Visa Support Service & Airport Transfers
Would you like us to apply for your Visa? __Yes __No
Would you like airport transfers? __Yes __No
Flight Number & arrival date and time:
___________________________________________________________________________
Flight Number & departure date and time:
___________________________________________________________________________
Part C. 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 the Tuition Deposit of
200 USD has been received.
Please also note: we must receive a full payment at least 30 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. 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 the completed and signed application
for your records and enclose your payment.
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