IPSA - International Partners for Study Abroad 



to English Language School in Washington, DC, USA

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 fees no later than 30 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: __________________ Passport number: ______________________ 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:

Which course do you want to attend? __Intensive English Course Morning __Intensive English Course Morning Plus Workshops: __1 __2 __3 __4 __Intensive English Course Evening __Intensive English Course Evening Plus Workshops: __1 __2 __3 __4 __Part-time English course __TOEFL Preparation __I want to attend Individual One-to-one classes ___ hours per week I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year) For how many weeks do you want to register: ____Number of weeks I will arrive on ________________________________ (Day-Month-Year) What is your present level of English? Speaking / Listening: __Beginner __Intermediate __Advanced Reading / Writing: __Beginner __Intermediate __Advanced Have you taken one of these English Tests? TOEFL. Date:______________________________ Score: ________________________ TWE. Date:______________________________ Score: ________________________ IELTS. Date:______________________________ Total Score: __________________ Reading: ______ Writing: _________ Listening: _______ Speaking: _________

Part C. Payment of Fees:

A non-refundable application fee of US$100, course registration of $85 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. Please note that your application will be considered only when your payment of the enrollment fees 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 should be paid in US Dollars. 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 a visa application if required. 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 my payment of the 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 and registration fees and 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: ___ enrollment fees and deposit ___ enrollment fees and full payment due Even if you select a "full payment" option, we will charge the application and registration fees and the tuition deposit at the time of accepting your application and will process the payment of the balance due to your credit card account 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 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: __________________ 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.