Day Telephone Number
Evening Telephone Number
Fax Number (optional)
Date of Birth (day-month-year)
Place of Birth (country, city):
I wish to book Weeks
I wish to start classes on: (Day) (Month) (Year)
I want to book the following course(s):
Standard Japanese. 20 lessons per week
Japanese for Exams. 20 lessons per week
If you selected the Japanese for Exams course, please list any Japanese exams you have passed (with scores, if possible):
If you are planning to take any further Japanese exams, please list them:
Japanese plus Culture. 25 lessons per week
If you selected the Japanese Culture course above, please select your interests from the list below:
Japanese Through Pop Culture. 25 lessons per week
If you selected the Japanese Through Pop Culture course, please select your interests from the list below:
Combination (20 lessons in Group + 5 private lessons per week)
Customized Japanese Program (10 conversational lessons in Group + 10 private lessons per week)
Please enter your comments if any:
What is your present level of Japanese?
Where and how long have you studied Japanese?
How many classroom hours of Japanese have you had?
Can you read hiragana and/or katakana?
How many kanji can you read?
What textbooks have you used?
Have you ever been to Japan before?
If so, where and for how long?
Do you want us to arrange Accommodations for you?
If yes, please select one of the following options:
Homestay (with breakfast)
Homestay (with half board)
Private Residence / guesthouse (private room, shared facilities)
Shared residence / dormitory (shared room, shared facilities)
Accommodation Arrival Information:
Accommodation Departure Information:
Do you smoke?
Do you have any allergies?
If yes, please list:
Do you require a special diet (i.e. Vegetarian)?
If yes, please specify:
Please give details of any special requirements relating to health, allergies, diet, etc.:
Do you want us to arrange airport transfer for you?
Please supply flight arrival information:
Arrival Time: (24 hour clock)
Airline and flight number:
Do you want us to arrange return airport transfer for you?
Please supply flight departure information:
Departure Time: (24 hour clock)
Airline and flight number:
A non-refundable application fee of US $100.00, course registration fee of $350.00 and a tuition deposit of $200 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 will be considered only when your payment of the enrollment fees and the tuition deposit has been received.
Upon receiving your application, enrollment fees and the tuition deposit, we will send you a registration confirmation and invoice.
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. The full payment must be paid before we can issue documentation in support of a visa application.
You may pay the balance by wire transfer, check or money order, or by credit card.
Please note that you may apply online only if you pay the enrollment fees and the tuition deposit by credit card.
You can also print out a from your browser, fill in your application and send it by post or by fax. If you use the printable application form, you can make your payment of the enrollment fees and deposits by credit card, check or international money order or by wire transfer to our bank account.
a monospaced printable application form
Payment by Credit Card
We accept VISA and MasterCard. In this Form, we utilize the Secure Socket Layer (SSL) authentication and RC4 128 bit encryption technology. SSL encryption protects information being transmitted across the internet to our processing center.
Please charge the application fee of US $100.00, the registration fee of $350.00 and the tuition deposit of $200 to my credit card provided below.
Please charge the enrollment fees and the full payment to my credit card provided below.
Even if you select a "full payment" option, we will charge only the enrollment fee and the deposit at the time of accepting your application and will process the payment of the balance to your credit card after registering you for the program. 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 enrollment fees and the tuition deposit by credit card.
Please select credit card:
(Month) / (Year)
Card Verification Value*:
* the last three digits on the back of your credit card after the credit card number. This value protects you from online fraud by verifying that you are in possession of the card you are attempting to use.
Cardholder Billing Information:
Zip (Postal) Code
Agreement and release.
By submitting 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 Study Abroad International 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 assume all risks and responsibilities and discharge IPSA and the study abroad program host and all their officers, agents and employees from and against any and all claims of damage to personal property 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 all terms and conditions and rules and agree to follow all IPSA and study abroad host procedures and regulations. 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.
Yes, I agree.
I don't agree