This form may also be completed and printed for later facsimile or parcel delivery.
Please complete all information on this form. All fields in
red
are required.
Last Name:
First Name:
Sex:
Male
Female
Occupation:
Date of Birth:
Describe Your Level of English:
Beginner
Intermediate
Advanced
Pre-Intermediate
Upper-Intermediate
Home address:
(in your country)
City:
State/Province:
Zip/Postal Code:
Country:
Email Address:
Home Telephone:
(Please don't forget Country and City code)
Business Telephone:
(Please don't forget Country and City code)
Fax:
(Please don't forget Country and City code)
You know The Language Academy from:
Agent
Yellow pages
Internet
Magazine
Other Student
Other
(please specify)
I will be studying (Please mark appropriate box)
General English - GEA1
General Intensive-GEB
Executive English
Executive Plus
Super Executive
Private Lessons
Teacher Training
General English GEC
(group + 5 private lessons)
General English- GED
(group + 10 private lessons)
TOEIC preparation
TOEFL preparation
Cambridge FCE preparation
Cambridge CAE preparation
Start Date of my course:
(month/day/year)
Number of weeks:
I wish to apply for a student visa:
Yes
No
Accommodations
I would like The Language Academy to arrange my housing:
Yes
No
Accommodation choices:
Homestay
Private Room
Shared Room
Hotel
Budget*
Standard**
Deluxe***
Deluxe Oceanside****
Apartment
Efficiency
Apartment
The Language Academy
- 200 South Andrews Avenue, Suite 401. Fort Lauderdale, FL 33301
Phone: 954.462.8373, Fax: 954.462.3738
Email:
english@languageacademy.com