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