Day Telephone Number
Evening Telephone Number
Fax Number (optional)
Date of Birth (day-month-year)
Place of Birth (country, city):
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?
b. What type of visa do you hold?
If you are not in the United States at this moment, on which Visa do you intend to enter the United States?
I wish to book Weeks
I wish to start classes on: (Day) (Month) (Year)
I am applying for the following program at Arizona Language Institute in Phoenix:
Intensive English ESL Courses:
Intensive General English course (20 group lessons a week)
Intensive Plus General English course (28 group lessons a week)
General English ESL Group Courses:
Part-time Morning English ESL Course
Part-time Afternoon Course
Part-time Evening Course
Part-time Saturday Course
English Language Literacy & U.S. Citizenship Test Preparation Program:
Private General English Classes
Private General English ESL Course with one-to-one lessons per week (10 lessons minimum)
Private General English ESL Classes Comments:
American English Pronunciation & Accent Reduction:
American English Pronunciation & Accent Reduction program with 20 one-to-one lessons
American English Pronunciation & Accent Reduction program with 40 one-to-one lessons
I want to book American English Pronunciation & Accent Reduction program with the total number of one-to-one lessons (if more than 40 one-to-one lessons)
Test Preparation Courses:
For how long have you studied English?
What is the student's present level of English?
Your English Learning Goals:
A non-refundable application fee of US$100.00 ($50.00 if you apply for the part-time or private General English ESL course) and the tuition deposit of $200.00 are required with your application. Please note that your application will be considered only when your payment of the application fee and the tuition deposit has been received.
Upon receiving your application and your payment of the application fee 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 if required.
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 application fee 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 application fee and the tuition deposit by credit card, check or international money order or by wire transfer to our bank account.
printable application form in PDF
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 ($50.00 if I apply for the part-time or private General English ESL course) and the tuition deposit of $200.00 to my credit card provided below.
Please charge the application fee and the full payment to my credit card provided below.
Even if you select a "full payment" option, we will charge only 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 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 application fee 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 Arizona Language Institute and/or IPSA websites constitute part of my agreement with Arizona Language Institute and/or IPSA, 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 Arizona Language Institute and/or IPSA and all their officers, agents, independent contractors 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 programs and courses, excursions, and/or on and off-campus activities. I have read all terms and conditions and rules and agree to follow all Arizona Language Institute and/or IPSA procedures and regulations. 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.
Yes, I agree.
I don't agree