IPSA - International Partners for Study Abroad
to English Language School in Los Angeles, 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 fees no later than 30 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: __________________
Do you need a student visa to study in Spain? __yes __no
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:
Which course do you want to attend?
__Full Time English Group course
__Part-time English Group course
__I want to attend Individual One-to-one classes ___ hours per week
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
For how many weeks do you want to register: ____Number of weeks
I will arrive on ________________________________ (Day-Month-Year)
What is your present level of English?
Speaking / Listening: __Beginner __Intermediate __Advanced
Reading / Writing: __Beginner __Intermediate __Advanced
Have you taken one of these English Tests?
TOEFL. Date:______________________________ Score: ________________________
TWE. Date:______________________________ Score: ________________________
IELTS. Date:______________________________ Total Score: __________________
Reading: ______ Writing: _________ Listening: _______ Speaking: _________
Do you want us to arrange accommodation for you? __yes __no
If yes, what form of accommodation?
__ Homestay with half-board
Do you smoke? __yes __no
Will you live in a house with children? __yes __no
Will you live in a house with pets? __yes __no
Are there any foods you cannot eat? __yes __no
If yes, please provide details: ___________________________________________
Part C. Payment of Fees:
A non-refundable application fee of US$150, course registration fee of $100
and a tuition deposit of US$200 are required with your application. The above
fees and the deposit are part of the cost of your program and are deducted
from the total of the program fees.
Please note that your application will be considered only when your payment
of the application and registration fees and the tuition deposit has been received.
Upon receiving your application and your payment of the required fee(s) and
the tuition deposit, we will send you a registration confirmation and
invoice for the balance due. The balance should be paid in US Dollars.
The payment of the balance of fees is due upon receipt of invoice. Your place
will be confirmed only when the full payment has been received. The full
payment must be paid before we can issue documentation in support of a visa
application if required.
You may pay by wire transfer, certified (cashiers) check/money order, or by
credit card. We accept Visa and Mastercard.
Payments of the application fee and deposit 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 my payment of the
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 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:
___ 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 due to your credit card account 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 Study Abroad International 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 assume all risks and responsibilities
and discharge IPSA and the study abroad program host and all their officers,
agents and employees from and against any and all claims of damage to
personal property or personal injury which may result from my enrollment and
participation in the study abroad program host courses, excursions, and/or
on and off-campus activities. I have read all terms and conditions and
rules and agree to follow all IPSA and study abroad host procedures and
regulations. This Agreement will be effective when my application is
accepted by IPSA and shall be governed by the laws of the State of Arizona.
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.