Arizona Language Institute
IPSA - International Partners for Study Abroad
Application to Arizona Language Institute
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
Arizona Language Institute
Enrollment Center
PO Box 7558
Cave Creek, AZ 85327, USA
or by Fax to: +1 (602) 942-6734
Application Deadlines
Normally, we must receive your application
no later than 30 days before the program starts.
Acceptance of late applications is subject to space availability.
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: __________________________________________________
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: ______________________________________
___________________________________________________________________________
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?
__Mini-Group English Course with 20 lessons a week in the morning.
__Evening Course (4 group lessons a week)
__Saturday Course (4 group lessons a week)
__GRE Preparation Course
__GMAT Preparation Course
__TOEFL Preparation Course
__TOEIC Preparation Course
__IELTS Preparation Course
Please also select one of the following:
__I want to attend group test preparation course with 20 lessons a week.
__I want to book test preparation package with 40 one-to-one lessons
__I want to book test preparation package with 20 one-to-one lessons
__Private English Course with 10 lessons a week
__Private English Course with 20 lessons a week
__Private English Course with 30 lessons a week
__Private English Immersion Course with 40 lessons a week
__I am applying for Weekend Private English Classes (min. 4 lessons a day)
__Weekend Private English Classes (min. 4 lessons a day)
Please enter the date(s) when you want to take Weekend classes:
Saturday: ____________ and the number of lessons per day : ____
Sunday: _____________ and the number of lessons per day : ____
Other Programs and Services:
__ English Classes Outside Classroom (min. 10 lessons a week)
Please enter the number of lessons per week : __
__ University Placement Service
If you selected a private course, please check the course options
which are of most interest to you:
English for Business:
__Business Correspondence
__Telephoning in English
__Business Grammar
__Management
__Business Vocabulary
__Making Presentations
__Negotiating Skills in English
__Marketing
__Business Law
__Introduction to Information Technology
General English:
__Conversational English for Everyday Purposes
__Reading for Comprehension and Vocabulary
__Writing Workshop
__American Idioms, Listening and Vocabulary
__Current Events and News Stories: Discussion & Debate
__News for Now
__English Grammar
__University Preparation
__Presentations and Public Speaking
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 ($50.00 if you apply for Evening
or Saturday course) 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 application fee and the tuition deposit has been received.
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:
Arizona Language Institute
Enrollment Center
PO Box 7558
Cave Creek, AZ 85327, 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
Arizona Language Institute and IPSA website constitute part of my agreement
with Arizona Language Institute and 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 Arizona 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 Arizona Language Institute procedures. This Agreement will be
effective when my application is accepted by Arizona Language Institute
and/or 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.
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