IPSA - International Partners for Study Abroad
Application
to Russian Language School in Moscow, Russia
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): ___________________
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, company:______________________________
___________________________________________________________________________
Necessary data for the issue of a Russian short term student visa:
Arrival not earlier than (month/day/year) _____/____/___________
Departure not later than (month/day/year) _____/____/___________
Passport number ________________________________________
Passport expiry date (month/day/year) _____/____/___________
Job position and full working address incl.. phone/fax:
___________________________________________________________________________
___________________________________________________________________________
Former visits to Russia or the USSR _______________________________________________
Year(s) (e.g. 1992, 93, 94)
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
When would you like to start your course:
Month: ______________ Day: _____ Year: ___________
For how many weeks you want to register? Number of weeks: ________
Which course would you like to study?
__Standard Group Russian Language Course
__Intensive Group Russian Language Course
__Academic Year Course: __2 terms __3 terms __4 terms
One-to-one Russian Language Courses:
__Leisure (15 lessons per week)
__Standard (20 lessons per week)
__Intensive (30 lessons per week)
__Crash (40 lessons per week)
__Total Immersion (20 lessons per week)
__Additional module (5 lessons per week)
Please note that you can combine a group course with individual one-to-one classes
__Exam Preparation Course (TRKI)
TRKI Preparation Module cannot be booked without a main course (group or one-to-one).
Russian on the River
__Cruise, preceded by two weeks of Group Course (60 lessons total):
___April 24: Moscow - Moscow __May 8: Moscow - Moscow
___July 17: Moscow - Moscow __Aug 28: Moscow - Moscow
__Cruise only:
___May 5: Moscow - Moscow __May 22: Moscow - Moscow
___July 29: Moscow - Moscow __Sept 10: Moscow - Moscow
Cabin type: __single __double
Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Part C. Accomodations.
Do you require help with accommodations? __yes __no
If yes,
I want my accommodotions to begin on - ____________________________________
and finish on _____________________________________________________________
Please select the accommodations you prefer:
__Homestay accommodation, Single room with half board
__Shared flat, Single room, self-catering
__Private apartment
__Hotel:
Other accommodation requirements and comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If you require homestay 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
___________________________________________________________________________
___________________________________________________________________________
Arrival information:
___________________________________________________________________________
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 and the Tuition Deposit in
the amount of $200 has been received.
Please also note that we must receive a full payment of tuition and
accommodation fees (a balance due) 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. The payment processing fee does not apply
to your payment of the application fee and the tuition deposit.
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 this completed and signed application
for your records and enclose your payment of the application fee. |