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 Application Deadlines 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 following information: 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: Financial Sourses: 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? __Yes __No 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: _______________________________________________________ Location: ____________________________________________________________ Date: ____________________________________________

Emergency Contact:

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

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 elective courses: __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: 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 fee and the 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 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. 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 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.