IPSA - International Partners for Study Abroad
to English Language School in Hackensack, New Jersey
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 (15 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): ___________________
Passport number: _________________ 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. If insurance is needed upon arrival, the
school will provide names of companies that will insure students for 12-180
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
a. If no, on which Visa do you intend to enter the United States? _________
b. Please note that Non-immigrant alien students' documents (I-20) are
provided for students taking a minimum of 20 lessons per week.
Part B. Program data:
I Wish to Book ____ weeks
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
Please choose the course:
__Advantage ESL Program
__Advantage Elite Intensive ESL Program
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?
__ High beginner
__ High Intermediate
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
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: _______________________________
Other accommodation 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:
A non-refundable application fee of US$100.00, course registration fee of
$150.00 and a tuition deposit of $200.00 are required with your application.
The Tuition Deposit is part of the cost of your course and is deducted from
the total tuition fees. The tuition deposit is not an additional cost.
Please note that your application will be considered as received only when
your payment of the enrollment fees and the tuition deposit has been
If you require our help with finding accommodations for you, please also pay
the accommodation finding fee of $100.00 with your application.
Upon receiving your application, enrollment fees and the tuition deposit, we
will send you a registration confirmation and invoice. The payment of the
balance of fees is due upon receipt of invoice. Your place will be confirmed
only when the full payment has been received. The full payment must be paid
before we can issue documentation in support of visa application (SEVIS I-20,
official Letter of Acceptence).
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:
___ enrollment fees and deposit ___ enrollment fees 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% convenience payment processing
service fee will be included in the invoice. There are no any additional
charges on your payment of the enrollment fees and the tuition deposit by
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.