Surname/Family Name:
First Name:
Sex
Male:
Female:
Date of Birth:
Address:
Nationality
Native Language/Mother Tongue
Other Languages:
Telephone Number
Email Address:
Study Dates:
From:
Day
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/
Month
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
/
Year
1975
1976
1977
1978
1979
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1987
1988
1989
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1991
1992
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2007
To:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
/
Month
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
/
Year
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
What level of English do you think you are?
Beginner:
Elementary:
Pre-intermediate:
Intermediate:
Upper-intermediate:
Advanced:
Secondary / High School Education
Name of School
From(Date):
To(Date):
Qualification
Third Level / University Education
Name of University
From(Date):
To(Date):
Qualification
Employment Details / Previous Experience
Name of Company
From(Date):
To(Date):
Job Description
Have you studied with us before?
Yes:
No:
If you marked yes, which level of English did you complete?
Beginner:
Elementary:
Pre-intermediate:
Intermediate:
Upper-intermediate:
Advanced:
Method of Payment
Cash:
Cheque:
Credit Card:
Please Note: Refunds are only made if:
1.) the course has been cancelled or 2.) the student can provide medical documentation
In the event that either of these two cases do apply:
all written documentation is required as proof
refunds will only be made to the original purchaser
all refunds will take at least three months as they have to be reviewed by a committee
