IPSA - International Partners for Study Abroad
Application
to London Central English Language School, UK
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: ______________________________________
___________________________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Status:
Are you a resident or national of any one of the European Union Member
States? __Yes __No
If your answer is no, you must apply for a course with at least 20 hours
of instruction per week to satisfy the requirements of the British
Immigration Authorities for full-time student status.
Part B. Program data:
I Wish to Book ____ Weeks,
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
Please check the course you would like:
Intensive / General English:
__15 lessons per week __20 lessons per week (AM)
__20 lessons per week (PM) __28 lessons per week
__General English (selected above) plus Private tuition
Cambridge Preparation Courses:
__First Certificate __10 weeks __20 lessons per week
__Advanced __12 weeks __28 lessons per week
__Proficiency __16 weeks
__ 8 weeks - Fast Track Courses
__Junior Summer Course in Southampton
__Junior Summer Course in Nottingham
Business English for Executives:
__Group Classes, Max 5:
__20 lessons per week __25 lessons per week __30 lessons per week
__35 lessons per week __1-19 lessons per week: __number of lessons
__One-to-One Executive Courses ___Lessons per week
__English for Teachers: ___2 weeks __4 weeks
__IELTS Preparation
__General English plus IELTS Preparation (a 4-week course)
__General English plus English for Bisuness
__Summer Vacation Courses - Adult
__English plus Work Experience: __3-4 weeks __5 and more weeks
__Christmas & New Year Course: __2002/2003 __2003/2004
__Study Year Abroad (SYA) Program: Please enter the dates below:
___________________________________________________________________________
Please note that accommodation in a shared room with breakfast and dinner
every day is included in the SYA program during course tutition sessions
(holiday breaks are not included).
If you require a single room, please check the following:
__Yes, I require a single room for an additional fee.
Please also check the appropriate if you require accommodation during
holiday breaks:
__Please reserve my accommodation during holiday break 1
__Please reserve my accommodation during holiday break 2
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
Accomodations:
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Homestay: Bed & Breakfast Room: __PRIVATE __SHARED
__Homestay: Bed, Breakfast & Dinner Room: __PRIVATE __SHARED
__School's Student Residence: Please specify which type of room and board:
____________________________________________________________________________
__Hotel: Please specify which one and type of room: ________________________
__________________________________________________________________________
1st choice: ________________________________________________________________
2nd choice: ________________________________________________________________
3rd choice: ________________________________________________________________
Do you smoke? __Yes __No Do you like pets? __Yes __No
Do you like children? __Yes __No
Do you have allergies to food/animals? List: _______________________________
____________________________________________________________________________
Accommodation will be arranged subject to availability.
Accomodation Arrival date: ________________ Checkout date: ________________
Do you require airport pickup? ___Yes __No
**Arrival date: ____________________________ **Time: _____________________
**Airline _________________________ **Flight Number: _____________________
**Without this information, airport pickup services can not be guaranteed.
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of US$75, accommodation placement fee
of $70 and deposits has been received.
The balance of fees is due no later than 30 days before the program starts.
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
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 and deposits.
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