IPSA - International Partners for Study Abroad
to English Language School in Queenstown, 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
Normally, we must receive a complete set of application documents
and a full payment no later than 21 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
Current college/university/graduate school: ______________________________
Major field of study: _____________________________________________________
Address of your college, university: ______________________________________
Relationship:______________________ Telephone: ________________________
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 Queenstown __in a Christchurch division __in both locations
Which course would you like to study?
__General English Part-time Morning Course
__General English Part-time Afternoon Course
__General English Full-time Course
__English Study & Ski/Snowboard Program
for __5 afternoons per week __3 afternoons per week; __in Christchurch
__Study & Activity
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?
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 US$100.00 and a tuition deposit of US$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 after conversion in New
Zealand Dollars. The tuition deposit is not an additional cost. Please note that
your application will be considered only when your payment of the application
fee and the tuition deposit has been received.
Upon receiving your application and required payments, we will send you an
e-mail (or fax) confirmation and invoice within four to five business days. The
confirmation will contain the details of your course and all pertinent costs.
The invoice will be issued in New Zealand Dollars. You can make a payment in
U.S. Dollars or in Euros according to the current exchange rates. 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. Once we receive your full payment,
you will be sent a certificate of enrolment for visa purposes and your housing
You may pay by wire transfer, certified (cashiers) check/money order, or by
credit card. We accept Visa and Mastercard.
Payments of the application fee and deposit 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 4.5% payment processing service fee
will be included in the invoice.
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 conditions 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: ___________________
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.