IPSA - International Partners for Study Abroad
Application
to IPSA Language Institute
in West Palm Beach
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
West Palm Beach Language Institute
224 Datura Street, Suite 1100
West Palm Beach, FL 33401, USA
or by Fax to: +1 (561) 629-5983
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: __________________ Passport number: ______________________
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: ______________________________________
___________________________________________________________________________
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 an F1 student currently in the United States, you can transfer to
our school. After we receive your application,we will send you the Transfer
Form upon your registation. You will need to bring this form to your current
school's student advisor and ask them to return the form to us by fax.
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? ___________
Do you request Express courier service to send you an I-20 for a student Visa?
__Yes __No
If yes, please note that an additional fee is required with your application
(the amount of the fee varies depending on destination - your country and city).
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
I Wish to Book: ____ Weeks
Which course would you like to study?
Intensive English ESL Courses (Downtown Campus):
__Intensive English course (20 group lessons a week)
Schedule: __AM __PM
__Intensive Plus English course (28 group lessons a week)
Intensive English Program for International F-1 Students
(Forest Hill Blvd. Campus):
__Intensive English Program for International F-1 Students (8 weeks min)
General English ESL Courses (Downtown Campus):
__Afternoon Course (4 group lessons a week)
__Evening Course (4 group lessons a week)
__Saturday Course (4 group lessons a week)
Private General English Classes (Downtown Campus)
__Private General English ESL Course with ___ one-to-one lessons per week
(10 lessons minimum)
Private General English ESL Classes Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
American English Pronunciation & Accent Reduction (Downtown Campus)
__American English Pronunciation & Accent Reduction 6-week program
with 4 group lessons a week
__I want to book American English Pronunciation & Accent Reduction program
with the total number of ____ one-to-one lessons (10 lessons minimum)
English for Specific Purposes Courses (Downtown Campus)
__American Idioms and Vocabulary Building
__English for Telephoning
__English in the Workplace
__English for Job Search Success
__Practical English Writing Skills Workshop
English for Specific Purposes courses are offered in mini-group classes for
our students enrolled in the Intensive General English Plus program and as
one-on-one lessons with flexible schedules.
Please select one of the following:
__I applied for the Intensive Plus program and want to attend the selected
English for Specific Purposes course(s) in mini-group
__I want to book the selected English for Specific Purposes course(s) with
the total number of ___ one-to-one lessons (10 lessons minimum)
Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Test Preparation Courses (Downtown Campus)
__TOEFL __TOEIC __IELTS
Test Preparation Courses are offered as group classes with 4 lessons per week
for 6 weeks and as one-on-one lessons with flexible schedules. Please select
one of the following:
__I want to attend the selected Test Preparation course for 6 weeks in group
__I want to book the selected Test Preparation course with the total number
of ____ one-to-one lessons (10 lessons minimum)
Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
English Courses for Executives and Professionals (Downtown Campus)
Mini-Group Courses for Executives and Professionals:
__Mini-Group Course for Executives and Professionals with 20 lessons a week
__I also want to book additional 10 one-to-one lessons per week
Private One-to-One Courses for Executives and Professionals:
__Private Executive English Course with 15 one-to-one lessons per week
__Private Executive English Course with 20 one-to-one lessons per week
__Private Executive English Course with 25 one-to-one lessons per week
__Private Executive English Course with 30 one-to-one lessons per week
__ Private Executive English Course with 35 one-to-one lessons per week
All English courses for Executives and Professionals are tailor-made and include
development of your general English language skills, remedial work on pronunciation
and accent reduction and vocabulary building and writing skills, specific to your
profession, as well as English for Specific purposes: telephone skills, meetings,
presentations, etc.
Upon registration we will send you the Executive Course Needs Analysis
that will help us assess your requirements and formulate a unique program
tailored to your needs.
Please select your program specialization:
__ General Executive English tailored to my specific learning needs
__ Business English for Executives
__ English for Accounting & Finance
__ English for Customer Care
__ English for Human Resources
__ English for Logistics
__ English for Marketing & Advertising
__ English for Sales & Purchasing
__ English for Aviation
__ English for Law Enforcement
__ English for Military
Please enter any comments below regarding your learning goals.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I also want to book English Classes Outside Classroom (min. 10 hours a week)
This program can be booked only in addition to any of our group and/or private
courses. Please enter the number of hours 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?
__Absolute Beginner __ Beginner with some knowledge __Elementary
__Low Intermediate __Intermediate __Advanced
What are your language learning goals:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Accomodations:
please select one of the following options:
__ Hotel
__ Condo/Apartment
__ Private House
__Host family
Please also answer the questions below:
Do you smoke? __Yes __No
Smoking is allowed only outside the residence.
Do you have allergies? List: _______________________________________
____________________________________________________________________________
Other 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 (intensive and executive courses)
or $50.00 (afternoon, evening and Saturday General English, Test preparation and
Accent Reductions courses), course registration fee of $150.00 (F-1 Students only)
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 is considered 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 $150.00 with your application.
Upon receiving your application, application fee and deposit, we will send you
a registration confirmation and invoice.
You may pay the balance by wire transfer, check/money order, or by credit card.
Please select one of the following payment options:
1. __Please find enclosed a certified check/money order for the registration
fee and the program 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:
West Palm Beach Language Institute
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 registration 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:
___ registration fee and deposit __ registration fee and the full payment
Even if you select a "full payment" option, we will charge the registration
fee and the program 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 registration fee and the program 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
West Palm Beach Language Institute and IPSA website constitute part of my
agreement with IPSA, agents, representatives 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 West Palm Beach
Language Institute and all their officers, agents and employees from and
against any and all claims of damage to personal property and/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 the terms and conditions of enrollment and agree to follow all West
Palm Beach Language Institute and IPSA procedures. This Agreement will be
effective when my application is accepted by IPSA and shall be governed
by the laws of the State of Florida, 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 and deposits.
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