IPSA - International Partners for Study Abroad
Application
to Spanish Language School in Granada, Nicaragua.
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 21 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:
The school offers Intensive Spanish Language Course (20 hours per week)
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
For how many weeks do you want to register: ____Number of weeks
__I also want to participate in the Volunteer Program
Please indicate what kinds of work you would be interested in:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What is your present level of Spanish?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Accomodations:
Do you require Homestay Accommodation? ___yes __no
If you require accommodations, 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:
___________________________________________________________________________
___________________________________________________________________________
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the Application Fee of 60 USD has been received.
Please also note: we must receive a full payment 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. Checks or
international money orders drawn on foreign banks will not be accepted.
You can also select one of the following payment options to pay
the application fee:
1. __Please find enclosed a certified check/money order for the application fee.
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 by wire transfer. Please send me the
instructions on how to send the wire transfer to your 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 only ___ application fee and full payment due
Even if you select a "full payment" option, we will charge only registration
fee 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 the selected options. 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 the completed and signed application
for your records and enclose your payment.
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