IPSA - International Partners for Study Abroad
to English Language School in San Francisco
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 your application
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): ___________________
SSN (U.S. citizens): _____-___-_______ 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
Current college/university/graduate school: ______________________________
Major field of study: _____________________________________________________
Address of your college, university: ______________________________________
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
My insurance company is: _________________________________________________
Policy Number: ____________________________________________________________
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
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 check the course you would like:
General English courses:
__28 lessons/week __22 lessons/week - AM __ 22 lessons/week - PM
__20 lessons/week - AM __20 lessons/week - PM
__General English plus Private (one-to-one) tuition.
This course offers a combination of class tuition for 20 or 28 lessons per
week plus one-to-one tuition of 5 lessons per week at a special combined
fee. If you want to register for this course please check this box and also
select a General English course above.
__International Semester Courses (ISC).
Discounted General English courses for students staying 24 weeks or more,
who want to gain maximum contact with English language and American life
and culture. ISC courses may include optional examination preparation for
IELTS, TOEFL, FCE, CAE or CPE. ISC students may choose to take optional
afternoon lessons in English for Business or extra IELTS preparation. These
options are included in the fees for full-day ISC courses, and are also
available for students taking ISC courses of 22 lessons at a supplementary
Please select a number of lessons of instruction per week:
__22 lessons/week __28 lessons/week
TOEFL Preparation courses: (4 and 6 weeks)
__20 lessons/week __22 lessons/week - AM
__TOEFL Preparation plus General English - lessons/week
General English plus ... courses:
__General English plus IELTS Preparation, 28 lpw, 4-week program.
__General English plus TOEIC Preparation, 28 lpw, 4-week program.
__General English plus English for Business, 28 lpw. (2 to 12 weeks)
__General English plus English for Tourism, 28 lpw. (4 weeks)
__General English plus English for Art and Design, 28 lpw. (4 weeks)
Cambridge Exams Preparation Courses:
__First Certificate (FCE)
Number of weeks: __9 weeks __12 weeks
Number of lessons per week:
__20 lessons per week, AM
__22 lessons per week, AM
__28 lessons per week
Platinum (Executive) General and/or Business English in mini-groups:
__20 hours/week - AM __25 hours/week __30 hours/week
__35 hours/week __15 hours/week (PM)
This program offers a combination of 20, 25, 30 or 35 group lessons a week
with an additional private lesson each day one-to-one (5 lessons per week),
and is for people who want to accelerate their progress during a short stay.
Private Platinum (Executive) General and/or Business English (one-to-one):
__ 20 hours/week __25 hours/week __30 hours/week __35 hours/week
__15 hours/week (PM)
__1 - 14 hours/week (PM). Please enter the number of lessons per week ____
One-to-one Platinum Weekend course
Please enter the number of lessons you wish to take during the weekend ____
Please enter the number of Telephone lessons you wish to book _______
(minmum 5 lessons. 30 minutes each lesson).
Please check your Private Platinum Course Specialization:
__Business for Beginners
__Secretaries, Personal Assistants and Administrative staff
__Preparation and entry for IELTS
__Preparation and entry for TOEFL
__ Teachers of English course (26 lessons per week)
__English plus Internship
Students choose an English course of 22 or 28 lessons per week for
4 weeks or more, followed by a period of internship of 12 weeks in
either Business Administration or Childcare.
__Junior Summer Camp
__The California Experience Program __2 weeks __ 3 weeks
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: Bed & Breakfast Room: __PRIVATE __SHARED
__Homestay: Bed, Breakfast & Dinner Room: __PRIVATE __SHARED
__Residence Club: Please specify which one and type of room/bath: __________
__Hotel: 1st choice: _____________________________________________________
2nd choice: _____________________________________________________
3rd choice: _____________________________________________________
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: _______________________________
Accommodation will be arranged subject to availability.
Accomodation Arrival date: ________________ Checkout date: ________________
Do you require airport pickup? ___Yes __No
(Cost is $60 to a private home or a Residence Club.)
**Arrival date: ____________________________ **Time: _____________________
**Airline _________________________ **Flight Number: _____________________
**Without this information, airport pickup services can not be guaranteed.
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of $125 USD and accommodation placement
fee of $75 has been received.
Please also send with your application a Tuition Deposit of $250 ($400 - if
you apply for a 16-week or longer program) and Accommodation Deposit of $100.
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.
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:
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
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% 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 deposits 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: ___________________
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.