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