IPSA - International Partners for Study Abroad 



to English Language School in Denver
CELTA Course

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 13832 N 32nd Street, Suite 151 Phoenix, AZ 85032, USA or by Fax to: +1 (602) 942-6734 I wish to apply for a place on the Cambridge RSA CELTA course starting on: __________________________________________________________________________

Personal details:

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): ___________________ SSN (U.S. citizens): _____-___-_______ Native language: __________________


Institution (University/College) Major Degree Dates GPA _________________________________ ___________ _________ _________ ________ _________________________________ ___________ _________ _________ ________ _________________________________ ___________ _________ _________ ________ Languages studied & level of proficiency: __________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Other Information:

Formal Training/Experience as a Teacher: EFL/ESL ____________________________________________________________________ Other_______________________________________________________________________ ____________________________________________________________________________ Other Professional Training/Experience: ____________________________________ ____________________________________________________________________________ Current Occupation: ________________________________________________________ Any other relevant information, including where you hope to work after the course: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________


Please supply the names of two people who could serve as references Reference #1 Name: ______________________________________________________________________ Street Address: ____________________________________________________________ City: ______________________ State:_________________ ZIP code:______________ Day telephone: _______________________ Evening Telephone: __________________ Fax: _______________________ Email: ________________________________________ Relationship: ______________________________________________________________ Reference #2 Name: ______________________________________________________________________ Street Address: ____________________________________________________________ City: ______________________ State:_________________ ZIP code:______________ Day telephone: _______________________ Evening Telephone: __________________ Fax: _______________________ Email: ________________________________________ Relationship: ______________________________________________________________ Are you a Colorado resident? yes___ no___ How did you hear about our program? ________________________________________ ____________________________________________________________________________

Emergency Contact:

Name: ________________________________________________________________ Relationship:______________________ Telephone: ________________________ Address: _____________________________________________________________

Status and Visa Information:

Are you NOW in the United States? __Yes __No If your answer is yes, a. Are you a citizen/permanent resident? __Yes __No 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 If no, on which Visa do you intend to enter the United States? _________


Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? __Homestay __Hotel: ___________________________________________________________________ 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: _______________________________ ____________________________________________________________________________ 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: _____________________

Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable Application Fee of $100 USD and the Tuition Deposit of $400 has been received. The balance of fees is due no later than 15 days before the program starts. All payments must be made in U.S. dollars and payable through U.S. banks. Any collection charges will be the applicant's responsibility. Certified Checks or money orders drawn on foreign banks will not be accepted. Certified Checks or money orders must be made payable to IPSA. You can also select one of the following payment options to pay the registration fee: 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 13832 N 32nd Street, Suite 151 Cave Creek, AZ 85331, 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 deposit by wire transfer. Please send me instructions on how to send the wire transfer to your 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 only ___ full payment Even if you select a "full payment" option, we will charge only registration fee 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: _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Agreement and release.

Declaration: Please read the following conditions carefully. Initial each section, and sign and date the final statement. Thank you. 1. The School/IPSA reserves the right to reject any application without explanation. _________ 2. Acceptance of an application does not constitute the reservation of a place on a course. A place is only considered reserved once the Enrollment Agreement has been signed and returned to the School with the relevant payment. _________ 3. The Certificate course is very intensive. Participants should be in a sufficiently good state of mental and physical health to be able to perform effectively during the course. I hereby grant permission to an appropriate medical facility for treatment or examination in the event of injury or illness while I am enrolled at the IPSA member school. I will also permit my medical information to be released as necessary for treatment or insurance purposes. _________ 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 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 program 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: ___________________ Please do not forget to make a copy of this completed and signed application for your records and enclose a completed Pre-Interview Task and your payment of the application fee and deposit.