IPSA - International Partners for Study Abroad
to English Language School in Denver
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
224 Datura Street, Suite 1100
West Palm Beach, FL 33401, USA
or by Fax to: +1 (561) 629-5983
Normally, we must receive a complete set of application documents
and fees no later than 30 days (21 days - if you do not need I-20)
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
Current college/university/graduate school: ______________________________
Major field of study: _____________________________________________________
Address of your college, university: ______________________________________
It is advisable that students have health insurance while residing or
traveling in the United States. The insurance carrier in the student's home
country can provide this coverage, or short term health coverage through an
American company can be arranged. The School now requires all students to
have health insurance. You must show proof of this before starting classes,
or we can offer this service for $78/month.
My insurance company is: _________________________________________________
Policy Number: ____________________________________________________________
Relationship:______________________ Telephone: ________________________
Status and Visa Information:
Are you NOW in the United States? __Yes __No
a. If your answer is yes, when did you come to the United States?
Month:___________________ Year: _______
b. What type of visa do you hold? ________________________________________
If you are not in the United States at this moment, do you wish to be sent
an I-20 for a student Visa? __Yes __No
If no, on which Visa do you intend to enter the United States? _________
Do you request Express courier service to send you an I-20 for a student
Visa? __Yes __No
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
(You can start classes on any Monday.)
How Many weeks do you plan to attend? Please enter a number of weeks______
I want to register for the following program: (Please check a program below)
__ Platinum Executive 1 Plus - Immersion plus "Live and Learn"
__ Platinum Executive 1 - Immersion
__ Gold Executive 2 - Group instruction + Private instruction
__ Silver Executive 3 - Group instruction (minimum enrolment: 4 weeks)
__ Executive Private Classes with ___ lessons per week (12 lessons a week minimum)
__I am interested in Family Package:
Intensive English Programs for Students
__Platinum Intensive English (minimum enrollment: 1 week)
__Gold Intensive English (minimum enrollment: 2 weeks)
__Silver Intensive English (minimum enrollment: 4 weeks)
__Academic English Program (minimum enrolment: 1 term)
__Student Private Classes with ___ lessons per week (12 lessons a week minimum)
__University Placement Service - Undergraduate
__University Placement Service - Graduate
Junior Winter Program
__Junior Winter program
__ add Ski/Snowboard Intensive Package
__Intensive GRE Preparation (12 weeks)
__One-on-one GRE Preparation classes (12 hours package)
__One-on-one GRE Preparation classes (36 hours package)
__IELTS Preparation (4 weeks)
__One-on-one IELTS Preparation classes (12 hours package)
__One-on-one IELTS Preparation classes (36 hours package)
Are you interested in TOEFL/TOEIC preparation courses?
Elective Course Options
Please check the course options which are of most interest to you:
English for Business: English & American Studies:
__Business Correspondence __Reading for Comprehension and Vocabulary
__Telephoning in English __Writing Workshop
__Business Grammar __American Film Series: American Idioms,
Listening and Vocabulary
__Management __Current Events and News Stories:
Discussion & Debate
__Business Vocabulary __News for Now
__Making Presentations __English Grammar
__Negotiating Skills __University Preparation
__Marketing __Presentations and Public Speaking
__Business Law __Conversational English for Everyday
__Introduction to Information
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
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Apart-Hotel (Homestead Village) __Hotel (Four Points Sheraton)
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: _______________________________
Please enter below your accommodation requirements (if any):
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.
Students opting for Host Family lodging will be picked up and delivered to
the airport by their host family provided they arrive or depart on a weekend.
Weekday pickup/delivery will be charged the airport pickup fee.
The School offers a limited number of cars for rental to executive students.
Please indicate if you would like to rent a car:
From: Day:___ Month:______________________________ Year:_______________
To: Day:___ Month:______________________________ Year:_______________
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable application fee of $155 and a tuition deposit of $350
has been received. The Tuition Deposit is part of the cost of your course
and is deducted from the total tuition fees.
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:
224 Datura Street, Suite 1100
West Palm Beach, FL 33401, 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
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 "full payment" option), a 4.5%
convenience payment processing service fee will be included in the invoice.
There is no any additional charge when you pay the application fee and the
tuition deposit by credit card.
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: ___________________
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.