IPSA - International Partners for Study Abroad
to English Language School in Fort Lauderdale, 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
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:
For how many weeks you want to register: Number of weeks: ______
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
Which course would you like to study?
__General English Plus
__Minigroup General English
__Private English __ lessons per week
__Business English plus General English
__Extended English Courses - General English Plus
__Extended English Courses - Intensive English
__FCE Cambridge Exam Course
__FCE Cambridge Exam Course Plus
__CAE Cambridge Exam Course
__CAE Cambridge Exam Course Plus
__TOEFL Preparation Programs
What is your present level of English?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Part C. Accomodations.
Do you require help with accommodations? __yes __no
If yes, please select the accommodations you prefer:
__Homestay, single room with breakfast
__Homestay, single room with half-board
__Homestay, shared room with breakfast
__Homestay, shared room with half-board
__La Quinta Inn Student Residence - Single Room
__La Quinta Inn Student Residence - Shared Room
__Shore Haven Standard Hotel Room - Single Room
__Shore Haven Standard Hotel Room - Shared Room
__Shore Haven Studio - Single Room
__Shore Haven Studio - Shared Room
Please give us details and your requirements, if you have selected Local
If you require accommodations, please also fill in below:
Are you a smoker? __yes __no
If you have a special diet, please specify:
If you have allergies, please specify:
If you have other requirements, please specify
Part D. Payment of Fees:
Please note that your application will be considered only when your payment of the
non-refundable application fee of $150, course registration of $105 and the tuition
deposit of $200 has been received.
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 enrollment fees 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% 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
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 Florida, 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.