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 Application Deadlines 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 following information: 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 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 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 fee. 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) __Advanced (CAE) __Proficiency (CPE) 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) __Platinum Plus. 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 ____ __Telephone lessons 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 __Finance __Human Resources __Journalism __Law __Medicine __Military __Secretaries, Personal Assistants and Administrative staff __Aviation __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. Vacation Courses: __Junior Summer Camp __Christmas Course __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: IPSA 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 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: ___ 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. 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: ___________________ 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.