EFTA00521677.pdf

Application Form = Summer 2019 Personal Information General Information 111. Title (Ms, Mrs, other) MS. 141. Company or Place of study LSJ Dental LW 112. First Name(s) / Given Name(s) Karyna 142. Sector or Major General Dentistry 113. Last Name(s) / Sumamefs) Shuliak 143. Job Title or Student Dentist 114. Father's Fist & Last Name(s) Fedor Chouliak Passport 121. Date of Birth (DD/MM/YYYYI 122. Place of Birth 123. Nationaitylies) United States of America 124. Passport # 125. Issued by (Country' USA 126. Vold From (DD/MM/YYYY) 13/06/2018 127. Vold Until (DD/MM/YYYY1 12/06/2028 128. Schengen visa: g I don't need a visa 0 I have a valid visa 0 I will need an attestation for the visa Communication 148. Have you already attended any Etiquette courses? 0 Yes gNo al giLii_A"i gn ii qfir General 146. Who recommended IVP? How did you find IVP? Ariane Rothschild 147. What do you hope to gain from the course? The ability to hold salons in New York 131. Mobile # (includinq country code Which one(s) 8 Where? 132. E-mail 133. Facebook 134. Twitter Mailing Address fr I SI. Title Ms. 152. First Nomefs)/ Given name(s) Karyna 153. Last Name(s)/ Sumame(s) Shuliak Select to copy info from "Personal Information" 154. Company 155. Position 156. Full Address 6100 Red Hook Quarters, suite B-3 157. City, Zip Code, State • St Thomas, VI 00802 158. Country USA 161. Direct Tel # (including country code) 162. E-mad or Fax # karynashuliak@icloucLcom 149. Do you work for the media press, TV, ...) 0 Yes 21 No, which one? Billing Address (if different from Mailing Address) 171. Title 172. Fist Name(s)/ Given name(s) 173. Last Name(s)/ Sumame(s) 174. Company 175. Position 176. Full Address 177. City, Zip Code, State I78. Country 181. Direct Tel# (including country code] 182. E-mail or Fax # 11 PDFfIller Document ID: 6305-0DB5-8336-0006 0 2019.06-CS V 1O EN VN-pn Rev: 2018.09-24 EFTA00521677 Booking Summary I I am booking: g 6 Weeks starting June 16, 2019 o 3 Weeks starting June 16, 2019 (to July 5) o 3 Weeks starting July 7. 2019 (to July 26) I have chosen to fake the following program: 11 Core Course (28 weekly periods) O Core Course without exams o Core Course with Higher Certificate tests & exams Diploma Course (36 weekly periods) g Diploma Course without exams o Diploma Course with Diploma tests & exams I MI be lodging: 0 On campus or Hotel Victoria "Resident Student" O Outside as a "Day student" - Please give us the address of where you will be staying. The payment according to the Financial Conditions on this Application Form can be done: g By Bank Transfer fo HIS SA (Bank). 41 Avenue du Casino. 1820 Montreux, Switzerland. Beneficiary: Institut Villa Pierrefeu SA, Route de Caux 28, 1823 Glion. Switzerland by fir/Swift UBSWCHZH80A or ARA 267 007 993 a/c N° 249-G5763255.0 IBAN: CH8I 0024 9249 G576 3255 0 att By Credit card with Visa, Mastercard or Amex and will incur a 3 -6". surchar•e. Date, Place, Student's Full Name & Signature 10/20/2018 USA Karyna Shuliak 12 Application Form (Fees in Swiss Francs) . Summer 2019 1. Application Fee & Deposit 3 Weeks I. 6 Weeks Total Application Fee (Also for returning students) CHF 600.. CHF 600.- CHF 600.- Deposit CHF 1'200.. CHF 2'400.- CHF 2'400.- Remainder refunded 60 days after the course ends Sub Total 1 - Application Fee S. Deposit Must be paid in full on application CHF 3'000.- (Weekly periods) 3 Weeks 6 Weeks Total 2.1 finishing Programs (taught In English) Core Course OR (Weekly 28) CHF 7'920.- CHF 15'840.- CHF 19'140.- IEP Diploma Course (Weekly 361 CHF 9'570.- CHF 19'140.- 2.2 Extras Books for Higher Certificate / Diploma CHF 450.- CHF 450.- CHF 450.- Exam Fees for Higher Certificate / Diploma CHF I '200.- CHF I '200.- Effective Communication (3 classes of I h30) CHF 480.- CHF 960.- CHF 960.- Oenology (3 classes of 1h30) CHF 480.- CHF 960.- Practical Housekeeping (3 classes of I h30) CHF 360.- CHF 720.- CHF 720.- Latin dance & transportation (3 classes of I h30) CHF 180.- CHF 360.- Private French language (3 lessons of 1 h30) CHF 660.- CHF 1'320.- The Art of Personal Presentation (3 hours once only) CHF 480.- CHF 480.- CHF 480.- Stress Release Made Easy (private class, per hour) CHF 250.- CHF 250.- Media training (private class, per hour) • CHF 360.- CHF 360.- Leadership training (private class, per hour) • CHF 360.- CHF 360.- CHF 360.- Diplomatic Protocol (private class. per hour) CHF 400.- CHF 400.- Chinese business etiquette (private class, per hour) • CHF 360.- • CHF 360.- Buffer & Efate Mgt (private class, per hour) • CHF 360.- CHF 360.- CHF 720.- • More sessions possible on request 2.3 Accommodation On campus, Double / Triple room sharing bathroom CHF 2'200.- CHF 4'400.- CHF 8'680.- On campus, Single room sharing bathroom CHF 2'880.- CHF 5'760.- At Hotel Victoria, Single room with own bathroom CHF 4'340.- CHF 8'680.- Sub Total 2 - Schools Fees (Program. Extras & Accommodation) CHF 31'510.- V PDFfiller Document ID: 6305-0DB5-8336-0006 I lg (stalling July) U 201955 CS V I 0 0,4 vN•pnkc 2018 "i•2 EFTA00521678 Application Form - Financial Conditions, etc Summer 2019 Art. I: GENERAL 1.1. Institut Vito Pieirefeu. S.A., Route de Caux 28, CH-1823 talon (Switzerland) thereafter "the School". 1.2. The Summer Course is donned over 6 weeks and preference is given to students applying to study the complete course. Please note that students who can only come for a shorter stay will not cover all of the material mentioned in the curriculum. 1.3. The school may amend the program, content cc location without notice. 1.4. Students must be over 18 years old to apply. Art. 2: DEFINMONS 2.1. The Application Fee is not refundable. 2.2. The Deposit depends on length of stay. It is used to cover personal miscellaneous expenses such as: books and stationery. extra courses and private lessons, visa handing, cultural events. etc. Note: The School cannot advance money to the students so they should arrive with their pocket money and travel tickets. Each student has a personal safe in her room fa her valuables. After the end of her sojourn. the student wil receive a detailed bil for miscedoneous expenses, the total of which win be deducted from the deposit and the balance refunded within 60 days of the student's departure. 2.3. School Fees: For "Resident students" the School fees include: the lessons for the chosen IEP coune, accommodation, breakfast and lunch Monday-Friday, the one Saturday full day excursion per 3 weeks, residence tax and contribution to the expenses for school 'edifies F. infrastructure. For "Day students": lessons for the chosen IEP course, lunch Monday to Friday, the one Saturday full day excursion per 3 weeks, contribution to the expenses for school facilities and infrastructure. Art.3: PAYMENTS 3.1. The "Application Fee" and the "Deposit- must be paid in full on application. 3.2. The "School Fees" must be paid by AprN PI for June entry: May PI fa July entry. 3.3. Late payment: places that have not been reconfirmed by the payment of the full fees when due wit be given to other candidates. 3.4. Credit Cord payment win incur a surcharge of 3%- 6%. Alt. 4: CANCELLATION AND REFUND 4.1. AN cancelatlons must be confirmed by registered letter. 4.2. The "Application Fee" is refunded only if the appicant cannot be accepted. 4.2. If cancelled before April friar June, May it for July. a cancellation fee of CHF l'000.- wit be charged. 4.3. If the letter is received after Apra 1** for June. May PI for July. and a student cannot be replaced, a cancellation fee of CHF 2'000.- per week. depending on the length of the stay booked, will be charged. 4.4. If the letter is received after Apri lr for June. May PI for July. and a student can be replaced by you, a total cancellation fee of CHF 1'500.- will be deducted from the deposit and fees pad to date, the remaining sum will be refunded. 4.5. Once the student has stated, she cannot cancel a reserved stay and only the balance of the deposit for miscellaneous expenses, if any, is refunded. 4.6. If a student is expelled or leaves before the end of her booked stay. only the balance of the deposit for miscellaneous expenses. if any. is refunded. 4.7. We strongly advice that you take out travel and cancellation insurance, in case you have to amend your plans for any reason. Ad. 5: REASONS FOR EXPULSION 5.1. Students wli be expelled who: fel to comply with the rules and regulations, having received one warning (no warning is given fa alcohol abuse, the possession, deaing or taking of drugs): persist with a negative attitude towards their studies, other students cc staff: behave in such a way as to damage the School's reputation. Art. 6: ABSENCES 6.1. No reductions or refunds will be made to a student who is absent during the course: is unable to attend a class: or cannot parlicjoate in an excursion or activity included in the program, whatever the reason may be. Art. 7: NON-DISCLOSURE & PRIVACY 7.1. The students shall respect. protect and maintain the privacy and confidentiality of al information relating to the other parties and shat not. during the period of this Agreement, Cf at any time after its termination. divulge any Information to any person without prior written authorization from the party involved. People working dkecIty or indirectly for the media must inform the school by filing point 149 under "General Information". 7.2. The student authorizes the School to use her image in any media form (picture. sound. video. ...) carefully selected by IVP for educational or promotional purposes (book, brochure. website, press, ...). Should you disagree, you must inforrn the School in writing. Art. 8: INTELLECTUAL PROPERTY 8.1. All of Institut Vila Pierrefeu's own class materials and the training you are receiving are copyrighted and fa personal use only. They cannot be used dkectly or indhectly for any commercial purposes (free or income generating - le. Educating, consulting, trailing, media.... 1st is non exhaustive) without a prior written licensing agreement being signed by the Principal and the corresponding fees being paid. By breaking this rule. the student agrees to indemnify the School for the expenses incurred as a result. Art. 9: LAW AND JURISDICTION 9.1. If the fees have not been paid by the requested date, they are considered as a debt within the meaning of Art. 82 LP. 9.2. This agreement is made under Swiss legislation, and it is farnaly agreed that Swiss jurisdiction shall be applied whatever may be the residence of the student. Legal residence is elected in Switzerland. in the Canton of Vaud, and any difficulties which might arise from the present agreement would be submitted for decision to the local court in Montreux/Vevey. This contract is valid once the student's application has been accepted in writing by IVP. Art. 10: SIGNATURE 10.1. Place, date and signature of the student who declares that having carefully read and huthfully completed the "Applicafion form'. the application documents (Bio, etc) and the financial conditions, she formally accepts them and will respect the School Rules and Regulations. Dale, Place, Student's Full Name & Signature 10/20/2018 USA tad Kr; PDFfiller Document ID: OS-ODDS:0336-0006 nA Shilliak Arriving at the School I ff!, Re,„Al CHECK-IN & CAMPUS TOUR The check-in of the students and campus tour is on Sundays June 16 and July 7 from 10 am to 3 pm. Please plan to arrive at the school during that time period. TRANSPORTATION From Geneva (GVA) Airport, Switzerland By private car: We can book a car for you at a rate of CHF 330.- to 360.- depending on the company. You should pay the driver in cash or by credit card (VISA and Mastercard are accepted). It takes 60-90 minutes to Montreux/Glion. In case you have reserved a car with us but don't use it, we will have to charge the initial amount plus VAT of 7.7%. By train: From the airport there ore direct trains to Montreux (75 min.) Then take a taxi (5 min.) to Glion. When you wont to go from the school to Montreux, you con either use: The train ( 15 minutes), the cable car (7 minutes) or a taxi (5 minutes). 13 D 2019-04-CS V 1 0 IN VW- pn Rev: 2018.09.24 EFTA00521679 Application Form - Medical History & Guarantee Summer 2019 Vaccinations & Da I o (if known: not compulsory but for information) O 611. Smallpox le 612. Diphtheria 05/24/2012 g 613. Whooping cough 05/24/2012 g 614. Tetanus 05/24/2012 le 615. Poliomyelitis 10/25/1995 lir 616. BCG 06/05/1989 yy 617. Hepatitis B 10/21/2003 Ce 618. Other Rubella, Measles, Mumps, General medical questions 621. Blood group and Rhesus factor (if known 622. Any post ilness. operations. serious accidents ? none Specify which onefsl: 623. Any physical or mental disabilities? none 624. Any known food allergies none 625. Are you vegetarian ? no 626. Are there any foods you cannot eat (for medical or religious reasons)? no lbO you have an international medical insurance? Yes, I am covered for the length of my stay Note: Students who study in Switzerland for less than 3 months must be insured for ilness and accidents and the insurance must be valid for the duration of their stay and cover them for expenses incurred in Switzerland. A credit card guarantee must be given in any case (below) so as to cover emergencies. as the hospitals generally demand a large deposit. To be completed by the cardholder By signing at the bottom of this page. I hereby authorise Institut Villa Pierrefeu S.A. (the school) to debit my cord to cover medical and other related expenses that: I or (applicant's name: Karyna Shuliak (her) sojourn at the School. ) may incur during my I understand that hospital and medical bills con get to the school up to 9 weeks after departure. 631. Card: 0 Mastercard 0 Visa // tar Amex 0 Diners 0 JCB _632. Card Number: 633. Card Expiration Date (mm/yy): 09/22 634. Cardholder's Name (as on cord): Karyna Shuliak 635. Cardholder's Address: 9 East 71St St, New York, NY 10021 627. Any other known allergies (medicines. etc)? no 628. Any prescribed medicines or drugs? no Date & Place 10/20/2018 USA Full name and Signature of the dent Karyna Shuliak • a Date & Place 10/20/2018 USA 14 PDFfIller Document ID: 6305-0DM-8336-0006 0 2019-06-CS V 1 0 EN VN-pn Rev: 2018.09.24 EFTA00521680