IPSA - International Partners for Study Abroad 



to English Language School in Auckland, New Zealand

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 Application Deadlines Normally, we must receive a complete set of application documents and a full payment no later than 40 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: _____________________________________________________________

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) I Wish to Book: ____ Weeks Where would you like to attend the course? __in Auckland __in a Christchurch division __in both locations Which course would you like to study? __General English Part-time Course __General English Intensive Course __General English Full-time Course __General English Full-time Plus Individual English Course __General English Individual Course and take __ hours of instruction per day __Cambridge Exam Preparation 12 weeks full-time Course __Cambridge Exam Preparation 9 weeks full-time Course __IELTS Preparation 6 weeks full-time Course __TOEIC Preparation 4 weeks full-time Course __English Plus Activity Program __English plus New Zealand Culture __Working Holiday Visa Program __Teenage School - English plus Activities program __Teenage School - Full-Time English program __TECSOL - Teaching English to Children 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? __Beginner __Elementary __Low Intermediate __Intermediate __Advanced

Part C. Accomodations.

Do you want us to arrange accommodation for you? __yes __no If yes, what form of accommodation? __Homestay __Furnished Apartment __Hostel __Hotel 5 Star __Hotel 3 Star __Bed and Breakfast __Backpacker (Dormitory) Do you smoke? __yes __no Will you live in a house with children? __yes __no Will you live in a house with pets? __yes __no Are there any foods you cannot eat? __yes __no If yes, please provide details: ___________________________________________________________________________ Will your husband, wife or other dependants join you in New Zealand? __yes __no Number of adults: ____ Number of children: _____ Do you want us to meet you at the Airport when you arrive? __yes __no Number of people arriving: ________________ Airline and flight number: _______________________________________________ Arrival date: ______________________________ Arrival time: _______________

Part D. Payment of Fees:

A non-refundable application fee of U.S.$100 and a Tuition Deposit of US$200 are required with your application. The above fees and the deposit are part of the cost of your program and are deducted from the total of the program fees after conversion them in New Zealand dollars according to the current exchange rate for buyers communicated by IPSA on the invoice date. Please note that your application will be considered only when your payment of the application fee(s) and the tuition deposit has been received. Upon receiving your application and your payment of the required fee(s) and the tuition deposit, we will send you a registration confirmation and invoice for the balance due. The balance may be paid in Euros or in U.S. Dollars. You may pay by wire transfer, certified (cashiers) check/money order, or by credit card. We accept Visa and Mastercard. 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 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 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 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 the study abroad program host and all their officers, agents and employees from and against any and all claims of damage to personal property 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 all terms and conditiones and rules and agree to follow all IPSA and study abroad host procedures and regulations. This Agreement will be effective when my application is accepted by IPSA and shall be governed by the laws of the State of Arizona. 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.