IPSA - International Partners for Study Abroad
to English Language School in Provo
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
13832 N 32nd Street, Suite 151
Phoenix, AZ 85032, USA
or by Fax to: +1 (602) 942-6734
Normally, we must receive a complete set of application documents
and fees no later than 40 days (21 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): ___________________
Native language: __________________
Other languages, if any: __________________________________________________
Do you have any special medical restrictions or conditions such as allergies
or dietary restrictions and/or physical handicaps that we should be aware of
and consider? __NO __YES
If Yes, please specify:____________________________________________________
I am aware that I must arrange for medical insurance for the total duration
of my stay in the USA. In the event of a medical emergency during my stay
in the USA, I authorize any licensed hospital or physician to initiate
treatment, and to release medical information for diagnostic and insurance
purposes for follow-up treatment in my home country at my cost. I absolve
IPSA and the school and their representatives from any liability for such
measures taken on my behalf. I am also aware that these declarations,
required by the American government authorities, are legally binding when
IPSA and the school accepts my application.
Health Insurance can be purchased either before leaving for or after
arriving at the school.
Relationship:______________________ Telephone: ________________________
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? _________
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
I want to register for the following program:
__Long-Term Semester Program (14 - 16 weeks) for one semester
__Long-Term Acaemic Program for ___semesters
__Short-term Program for ____weeks
__Executive English Program for ____weeks
__English Adventure Program for ____weeks
Please note that you can apply for this program ONLY if you are arriving
with other students in your group of 5 or more students)
__Tutor One-to-one course In addition to the above selected Semester
or Short Term program, I want to take __one-to-one lessons per day
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 __Elementary __Low Intermediate __Intermediate __Advanced
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Homestay __Apartment Rental for Single person
__Apartment Rental for Family __Home Rental __Hotel
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: _______________________________
Please enter below your accommodation requirements (if any):
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$150.00, course registration fee of
$100.00 and a tuition deposit of $250.00 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.
If you require accommodation, please also pay the homesaty placement fee
of $155.00 with your application.
Please note that your application will be considered only when your payment
of the enrollment fees and the tuition deposit 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:
13832 N 32nd Street, Suite 151
Cave Creek, AZ 85331, 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
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% 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.
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: ___________________
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.