IPSA - International Partners for Study Abroad
Application
to English Language School in Denver
CELTA Course
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
I wish to apply for a place on the Cambridge RSA CELTA course starting on:
__________________________________________________________________________
Personal details:
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: __________________
Education:
Institution (University/College) Major Degree Dates GPA
_________________________________ ___________ _________ _________ ________
_________________________________ ___________ _________ _________ ________
_________________________________ ___________ _________ _________ ________
Languages studied & level of proficiency: __________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Other Information:
Formal Training/Experience as a Teacher:
EFL/ESL ____________________________________________________________________
Other_______________________________________________________________________
____________________________________________________________________________
Other Professional Training/Experience: ____________________________________
____________________________________________________________________________
Current Occupation: ________________________________________________________
Any other relevant information, including where you hope to work after the
course:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
References
Please supply the names of two people who could serve as references
Reference #1
Name: ______________________________________________________________________
Street Address: ____________________________________________________________
City: ______________________ State:_________________ ZIP code:______________
Day telephone: _______________________ Evening Telephone: __________________
Fax: _______________________ Email: ________________________________________
Relationship: ______________________________________________________________
Reference #2
Name: ______________________________________________________________________
Street Address: ____________________________________________________________
City: ______________________ State:_________________ ZIP code:______________
Day telephone: _______________________ Evening Telephone: __________________
Fax: _______________________ Email: ________________________________________
Relationship: ______________________________________________________________
Are you a Colorado resident? yes___ no___
How did you hear about our program? ________________________________________
____________________________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Status and Visa Information:
Are you NOW in the United States? __Yes __No
If your answer is yes,
a. Are you a citizen/permanent resident? __Yes __No
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? _________
Accomodations:
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Homestay
__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: _______________________________
____________________________________________________________________________
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: _____________________
Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of $100 USD and the Tuition Deposit of
$400 has been received.
The balance of fees is due no later than 15 days before the program starts.
All payments must be made in U.S. dollars and payable through U.S. banks. Any
collection charges will be the applicant's responsibility. Certified Checks
or money orders drawn on foreign banks will not be accepted. Certified Checks
or money orders must be made payable to IPSA.
You can also select one of the following payment options to pay
the registration fee:
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
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 deposit by wire transfer. Please
send me instructions on how to send the wire transfer to your 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 only ___ full payment
Even if you select a "full payment" option, we will charge only registration
fee 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.
Comments: _________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Agreement and release.
Declaration:
Please read the following conditions carefully. Initial each section, and
sign and date the final statement. Thank you.
1. The School/IPSA reserves the right to reject any application without
explanation. _________
2. Acceptance of an application does not constitute the reservation of a
place on a course. A place is only considered reserved once the
Enrollment Agreement has been signed and returned to the School with
the relevant payment. _________
3. The Certificate course is very intensive. Participants should be in a
sufficiently good state of mental and physical health to be able to
perform effectively during the course. I hereby grant permission to an
appropriate medical facility for treatment or examination in the event
of injury or illness while I am enrolled at the IPSA member school. I
will also permit my medical information to be released as necessary for
treatment or insurance purposes. _________
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 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 program 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 a completed Pre-Interview Task and your payment
of the application fee and deposit.
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