SECTION 1. PERSONAL DETAILS

First Name*

Last Name*

D.o.B.*

Age:*

Gender:*

Female Male

Home Tel N°  (country code first)

-

Work Tel N°  (country code first)

-

Mobile Tel N°  (country code first)

-

Fax N° (country code first)

-

E-mail

Address Line 1*

Address Line2

City*

County/State*

Zip/Postal Code*

Country*

Albania Algeria Andora Argentina Armenia Australia Austria Azerbaijan Bahamas Belarus Belgium Bosnia-Herzegovina Botswana Brazil Bulgaria Cameroun Canada Canary Islands Cayman Islands Chile China Colombia Costa Rica Croatia Cyprus Cezch Rupublic Cezchslovakia Democratic Republic of Congo Denmark Dominician Republic Ecuador Egypt El Salvador Estonia Faroe Islands Finland France Georgia Germany Ghana Greece Greenland Guatemala Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kenya Latvia Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malasyia Malta Mexico Monaco Mongolia Morocco Nambia New Zealand Nigeria Norway Pakistan Panama Peru Phillipines Poland Portugal Romania Russia Salvadore San Marino Seychelles Singapore Slovak Republics Slovenia South Africa South Korea Spain Swaziland Sweden Switzerland Taiwan Tanzania Thailand Togo Trinidad and Tobago Turkey Uganda Ukraine United Kingdom United States of America Unlisted Venezuela Yugoslavia Zambia Zimbabwe

Next of kin (if different from above) Address Line 1:

Next of kin Address Line 2:

Next of kin City:

Next of kin County/State:

Next of kin Zip/Postal Code:

Next of kin Country:

Albania Algeria Andora Argentina Armenia Australia Austria Azerbaijan Bahamas Belarus Belgium Bosnia-Herzegovina Botswana Brazil Bulgaria Cameroun Canada Canary Islands Cayman Islands Chile China Colombia Costa Rica Croatia Cyprus Cezch Rupublic Cezchslovakia Democratic Republic of Congo Denmark Dominician Republic Ecuador Egypt El Salvador Estonia Faroe Islands Finland France Georgia Germany Ghana Greece Greenland Guatemala Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kenya Latvia Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malasyia Malta Mexico Monaco Mongolia Morocco Nambia New Zealand Nigeria Norway Pakistan Panama Peru Phillipines Poland Portugal Romania Russia Salvadore San Marino Seychelles Singapore Slovak Republics Slovenia South Africa South Korea Spain Swaziland Sweden Switzerland Taiwan Tanzania Thailand Togo Trinidad and Tobago Turkey Uganda Ukraine United Kingdom United States of America Unlisted Venezuela Yugoslavia Zambia Zimbabwe

Next of kin Tel N°: (country code first)

-

Marital Status*

Divorced Living together Married Seperated Single

Present Employment:*

What is your mother tongue?*

Afrikaans Albanian Arab Armenian Azerbaijani Belorusan Bengali Bosnian Bulgarian Burmese Cezch Croatian Danish Dzongkha English Estonian Faroese Farsi Finnish Flemmish French Georgian German Greek Greenlandic Hebrew Hindi Hungarian Icelandic Indonesian Irish Italian Japanese Kazakh Khmer Kirghiz Korean Lao Latvian Lithuanian Macedonian Malay Maldivian Mandarin Cinese Marshallese Mongolian Nepali Norwegian Panjabi Polish Portuguese Romanian Russian Serbian Sinkala Slovak Slovenian Spanish Swahili Swedish Tajiki Tamil Thai Turkish Turkmenistan Tuvalvan Ukranian Urdu Uzbek Vietnamese

Do you speak any foreign languages?

To make multiple selections hold down the ctrl key Afrikaans Albanian Arab Armenian Azerbaijani Belorusan Bengali Bosnian Bulgarian Burmese Cezch Croatian Danish Dzongkha English Estonian Faroese Farsi Finnish Flemmish French Georgian German Greek Greenlandic Hebrew Hindi Hungarian Icelandic Indonesian Irish Italian Japanese Kazakh Khmer Kirghiz Korean Lao Latvian Lithuanian Macedonian Malay Maldivian Mandarin Cinese Marshallese Mongolian Nepali Norwegian Panjabi Polish Portuguese Romanian Russian Serbian Sinkala Slovak Slovenian Spanish Swahili Swedish Tajiki Tamil Thai Turkish Turkmenistan Tuvalvan Ukranian Urdu Uzbek Vietnamese

Nationality:*

Albania Algeria Andora Argentina Armenia Australia Austria Azerbaijan Bahamas Belarus Belgium Bosnia-Herzegovina Botswana Brazil Bulgaria Cameroun Canada Canary Islands Cayman Islands Chile China Colombia Costa Rica Croatia Cyprus Cezch Rupublic Cezchslovakia Democratic Republic of Congo Denmark Dominician Republic Ecuador Egypt El Salvador Estonia Faroe Islands Finland France Georgia Germany Ghana Greece Greenland Guatemala Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kenya Latvia Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malasyia Malta Mexico Monaco Mongolia Morocco Nambia New Zealand Nigeria Norway Pakistan Panama Peru Phillipines Poland Portugal Romania Russia Salvadore San Marino Seychelles Singapore Slovak Republics Slovenia South Africa South Korea Spain Swaziland Sweden Switzerland Taiwan Tanzania Thailand Togo Trinidad and Tobago Turkey Uganda Ukraine United Kingdom United States of America Unlisted Venezuela Yugoslavia Zambia Zimbabwe

Do you: Smoke?*

Choice of country:*

England France Germany Ireland Italy Japan Scotland Spain Switzerland USA

Choice of city:*

Alexandria Amboise Barcelona Bath Brighton Bournemouth Cambridge Cologne Dublin Edinburgh Florence Kanazawa La Rochelle Lausanne London Lucerne Madrid Neuchatel Oxford Paris Weimar

Date course starts:*

4th January 1st Febuary 1st March 29th March 12th April 10th May 11th May 7th June 8th June 21st June 29th June 5th July 6th July 13th July 20th July 27th July 2nd August 3rd August 17th August 30th August 31st August 7th September 27th September 28 September 25th October 20th November 2002 2003 2004 2005

Date Course ends:*

30th January 27th March 30th March 6th June 19th June 3rd July 4th July 18th July 25th July 31th July 1st August 8th August 15th August 22nd August 28th August 29th August 5th September 25th September 26th September 24th October 18th December

N° of weeks required:*

2 weeks 3 weeks 4 weeks 6 weeks 8 weeks 10 weeks 12 weeks

Course N°:

11.92.30 11.92.31 11.92.32 11.92.33 15.92.31 15.92.32 16.92.31 16.92.32 17.92.31 17.92.32 19.92.31 19.92.32 21.92.31 21.92.32 21.92.33 22.92.31 22.92.32 23.92.31 23.92.32 23.92.33 25.92.31 25.92.32 26.92.31 26.92.32 26.92.33 26.92.34 31.92.31 31.92.32 31.92.33 41.92.32 41.92.33 41.92.34 42.92.30 42.92.31 42.92.32 42.92.33 51.92.31 51.92.32 51.92.33 52.92.31 52.92.32 53.92.31 53.92.32 61.92.21 61.92.22 61.92.31 61.92.32 61.92.33 61.92.41 82.92.31 82.92.32 83.92.31 83.92.32 93.92.30 93.92.31 93.92.32 93.92.33

Type of course required:

A B C D

How do your rate your current level of the language?*

0 1 2 3 4 5 6 7 8 9 10

Have you already attended a language course through our agency?*

  SECTION 2. ACCOMMODATION

In a private home:

In a hotel: (Paris, London)

Category without private bathroom:

Single Room:Double Room:

Category with private bathroom:

Single Room: Double Room:

In a student residence: (Oxford)

Single Room:Double Room:

Other useful information: (allergies, particular diet etc)

  SECTION 3.SPECIAL SERVICES

When possible would you like to receive details about your journey? *

Would you like to receive information on insurance?*

How did you find our web site?*  Please quote Ref N° if applicable:

1) The agency fee is £99.00. It is inclusive of all expenses. The fee is payable on application. 2) In the event of cancellation or failure to arrive on your part, the agency fee will under no circumstances be reimbursed. 3) If we are unable to satisfy your application the entire fee will be reimbursed. 4) Whilst every precaution is taken with the presentation of clients, we decline any responsibility for unpredictable and unforeseen causes. 5) The course and accommodation fees must be paid to the agency at least 6 weeks prior to the commencement of the course. When application is received less than 6 weeks prior to commencement of the course the amount due is payable immediately. 6) On application a registration fee of £43.00 is due (non refundable) 7) At the beginning of the course every student must produce receipt of payment. 8) The address of the accommodation will be communicated about 2 weeks after registration but not before 3 months from commencement of course. 9) Delay in the payment of fees due can result in cancellation of registration. 10) Cancellation of registration must be notified at least the Friday before the commencement of the course. In that case the whole course and accommodation fees will be refunded. The registration fee and agency fee is not refundable. 11) In the event of failure to arrive at a course without notification as per point 10 or in the event of withdrawal from a course, or if you do not attend a course no refund will given on course fees. In the event of financial difficulties or serious health problems or an accident a refund will be at the discretion of the college. However course fees for a Year of Academic Study are not refundable under any circumstances. 12) If you leave your accommodation after the start of a course, 2 week’s notice is needed (finishing Saturday). 2 week’s rent can be paid instead of the notice. The rest of the accommodation fee will be refunded. 13) Participants are not insured for illness, injury, theft or loss of personal belongings whilst attending the college or in a family home. It is advisable, therefore to undertake a private insurance. totalnannies.com can assist you in this. 14) The school is usually closed during local and national holidays.