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 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: __________________________________________________ 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:

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 __General English Plus __Minigroup General English __Intensive English __Minigroup Intensive English __Private English __ lessons per week __Business English __FCE Cambridge Exam Course __FCE Cambridge Exam Course Plus __CAE Cambridge Exam Course __CAE Cambridge Exam Course Plus __Cambridge BCE Preliminary __Cambridge BCE Vantage __TOEFL Preparation Programs __TOEIC Preparation Programs __IELTS 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 Hotel: __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 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 USD, course registration of $100.00 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: ___ application fee and deposit ___ application fee 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. 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: _____________________ 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.