IPSA - International Partners for Study Abroad 

                       

Application

to English Language School in Newark, New Jersey

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 Application Deadlines Normally, we must receive a complete set of application documents and fees no later than 30 days (15 days - if you do not need I-20) 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): ___________________ Passport number: _________________ 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: ______________________________________ ___________________________________________________________________________

Insurance:

It is advisable that students have health insurance while residing or traveling in the United States. The insurance carrier in the student's home country can provide this coverage, or short term health coverage through an American company can be arranged. If insurance is needed upon arrival, the school will provide names of companies that will insure students for 12-180 days. My insurance company is: _________________________________________________ Policy Number: ____________________________________________________________

Emergency Contact:

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

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 a. If no, on which Visa do you intend to enter the United States? _________ b. Please note that Non-immigrant alien students' documents (I-20) are provided for students taking a minimum of 20 lessons per week.

Part B. Program data:

I Wish to Book ____ weeks I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) Please choose the course: __Intensive Group Course __ lessons per week __TOEFL Preparation __Business English __ lessons per week I have studied English for __Years at a ____________________________________ ____________________________________________________________________________ (type of school e.g. high school, university, private language school) What is your present level of English? __ Beginner __ High beginner __ Intermediate __ High Intermediate __ Pre-Advanced __ Advanced

Accomodations:

Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? __Host Family __YMCA (hostel) __Apartment share 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: _______________________________ ____________________________________________________________________________ Other accommodation requirements: ____________________________________________________________________________ ____________________________________________________________________________ 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: _____________________ **Without this information, airport pickup services can not be guaranteed.

Part C. Payment of Fees:

A non-refundable application fee of US$100.00, course registration fee of $150.00 and a tuition deposit of $200.00 are required with your application. The Tuition Deposit is part of the cost of your course and is deducted from the total tuition fees. The tuition deposit is not an additional cost. Please note that your application will be considered as received only when your payment of the enrollment fees and the tuition deposit has been received. If you require our help with finding accommodations for you, please also pay the accommodation finding fee of $100.00 with your application. Upon receiving your application, enrollment fees and the tuition deposit, we will send you a registration confirmation and invoice. 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 visa application (SEVIS I-20, official Letter of Acceptence). 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 13832 N 32nd Street, Suite 151 Phoenix, AZ 85032, 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 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% convenience payment processing service fee will be included in the invoice. There are no any additional charges on your payment of the enrollment fees and the tuition deposit by credit card. 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 and deposits.