IPSA - International Partners for Study Abroad
Application
to English Language School in Phoenix, Arizona
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
no later than 30 days before the program starts.
Acceptance of late applications is subject to space availability.
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) _______________(Month) ________(Year)
I Wish to Book: ____ Weeks
Which course would you like to study?
__Private English Course with 10 lessons a week
__Private English Course with 20 lessons a week
__Private English Course with 30 lessons a week
__Private English Immersion Course with 40 lessons a week
__Weekend Private English Classes (min. 4 lessons a day)
Please enter the date(s) when you want to take Weekend classes:
Saturday: ____________ and the number of lessons per day : ____
Sunday: _____________ and the number of lessons per day : ____
__Private Tutoring for Local Students (min. 2 lessons a day, minimum package
is 20 lessons)
If you selected Private tutoring, please enter
total number of lessons booked (1 lesson = 45 min): ________
the number of lessons per day: _______
and your preferred schedule of classes:
___________________________________________________________________________
___________________________________________________________________________
Please also let us know where you want to take classes (school, office, library):
___________________________________________________________________________
Semi-Private Two-to-One English Language Courses
If you want to select this option, please enter the following information:
Name of the second person attending the course: ______________________________
Date of Birth: __________________ Native language: __________________________
__Semi-Private English Course with 20 lessons a week
__Semi-Private English Course with 30 lessons a week
__Semi-Private English Immersion Course with 40 lessons a week
__Mini Group English Language Course
__Combo English Language Course
__I also want to book "Classes outside the classroom"
Please enter the number of lessons per week : _______
Note: This is an additional course to any of our Group or Private courses.
__University Placement Service
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?
__Absolute Beginner __ Beginner with some knowledge __Elementary
__Low Intermediate __Intermediate __Advanced
What are your language learning goals:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Accomodations:
please select one of the following options:
__ School Residence, single room, shared bath
__ School Residence, double room, shared bath - single occupancy
__ School Residence, double room, shared bath - double occupancy
(for two persons arriving together)
__ School Residence, suite, private bath - single occupancy
__ School Residence, suite, private bath - double occupancy
(for two persons arriving together)
__ Hotel
__ Condo/Apartment
__ Private House
Please also answer the questions below:
Do you smoke? __Yes __No
Smoking is allowed only outside the residence.
Do you have allergies? List: _______________________________________
____________________________________________________________________________
Other requirements:
____________________________________________________________________________
____________________________________________________________________________
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 registration fee of $150 and a Program Deposit of $350
has been received. Registration fees and deposits are per person.
The full payment of the tuition and accommodation fees is due upon receipt
of the invoice. Your place will be confirmed only when the full payment has
been received.
Please select one of the following payment options:
1. __Please find enclosed a certified check/money order for the registration
fee and the program 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 registration 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:
___ registration fee and deposit __ registration fee and the full payment
Even if you select a "full payment" option, we will charge the registration
fee and the program 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% convenience payment processing
service fee will be included in the invoice. There are no any additional
charges on your payment of the registration fee and the program deposit by
credit card.
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
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 study abroad program host and all their officers, agents and employees
from and against any and all claims of damage to personal property and/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 the terms and conditions of enrollment 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: _____________________
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.
|