IPSA - International Partners for Study Abroad
to English Language School in College Park, Maryland, 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: __________________________________________________
Permanant Residency Country: _____________________________________________
Passport Number _________________________
Social Security Number: (if you have one) _______________________
SEVIS Number: (if you have one) ______________________________
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: ______________________________________
Status and Visa Information
Are you NOW in the United States? __Yes __No
a. If your answer is yes, when did you come to the United States?
Month: ____________________ Year: ___________
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? _______________
If you requested the I-20 form (new and transferring F-1 students), please
answer the following questions:
a. Personal Savings. Please enter the amount: ______________
b. Family or Sponsor. Please enter the amount: ______________
Name of the Sponsor: _________________________________
Relationship to the student: ______________________________
c. Government/Employer/Scholarship. Please enter the amount: ______________
d. Other. Please enter the amount: _____________________
Source of funding: _______________________________________________
Total minimum amount to show for the I-20. Summer program: $8,400.00.
Semester program (one semester): $13,800.00.
Original bank statements and award letters will be required upon registration.
US sponsors must complete the I-134 form.
Will you spouse and/or childre accompany you? __Yes __No
If yes, you must show the evidence of an additional $4,500 of financial resorces per year
for each dependent.
Please enter the name, date of birth, city and country of birth, country of
citizenship and relationship for each dependent that will accompany you:
Do you plan to study at another institution in the U.S. after completing
the course at our school?
If yes, at which institution: ________________________________________________
Last School Attended (name): _____________________________________________
Last School Attended (dates): ____________________________________________
Highest certificate, diploma or degree earned:
Type of certificate: _____________________________________________________
Name of school: _______________________________________________________
Relationship:______________________ Telephone: ________________________
Part B. Program data:
For how many sessions you want to register: Number of sessions: ______
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
Which course would you like to study?
__ Fall Semester Intensive English Program
__Spring Semester Intensive English Program
__Summer Intensive English Program
In addition to the core summer program, I want to attend the following
__Strategies for Success on the iBT TOEFL
__ Preparation for Academic Study
__ Focus on Pronunciation
__ Focus on Conversation
__ Read Faster, Understand More
__ Focus on Grammar
What is your present level of English?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of $100 USD, course registration
fee of $110 and the tuition deposit of $200 USD 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 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:
___ enrollment fees and deposit ___ enrollment fees and full payment
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 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 your payment of the application fee.