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SECTION
1. PERSONAL DETAILS |
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Fill in the application form on-line.
Please answer all |
questions. All fields marked with a
*
are required and
must be completed
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Once your
application has been received you will be given |
a reference N°
that you will need to quote on all
correspondence, e-mails or
when contacting us by
telephone
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We offer SSL
on-line secure credit card
payment. For your convenience if you prefer, you can
fax us
your application
with your credit card details. We also accept
credit card payment over the phone,
cheques and
bank transfers.
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First Name* |
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Last Name* |
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D.o.B.* |
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Age:* |
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Gender:* |
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Home Tel N°
(country
code first) |
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Work Tel N°
(country
code first) |
- |
Mobile Tel N°
(country
code first) |
- |
Fax N°
(country
code first) |
- |
E-mail |
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Address Line 1* |
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Address Line2 |
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City* |
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County/State* |
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Zip/Postal Code* |
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Country* |
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Next of kin
(if different from above) Address Line 1: |
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Next of kin
Address Line 2: |
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Next of kin
City: |
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Next of kin
County/State: |
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Next of kin
Zip/Postal Code: |
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Next of kin
Country: |
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Next of kin Tel N°:
(country
code first) |
-
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Marital Status* |
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Present Employment:* |
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What is your
mother tongue?* |
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Do you speak
any foreign languages? |
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Nationality:* |
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Do you: Smoke?*
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Choice of country:* |
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Choice of city:* |
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Date course starts:* |
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Date Course ends:* |
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N°
of weeks required:* |
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Course N°: |
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Type
of course required: |
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How
do your rate your current level of the language?* |
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Have
you already attended a language course through our agency?* |
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SECTION 2. ACCOMMODATION |
Choice of Accommodation:*
In
a private home: |
Single Room
Double Room:
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In a hotel:
(Paris, London) |
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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) |
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Do
your intend to travel by car? (parking cannot be guaranteed):*
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SECTION 3.SPECIAL SERVICES |
When
possible would you like to receive details about your journey?
* |
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Would
you like to receive information on insurance?*
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How
did you find our web site?*
Please quote Ref N° if applicable: |
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SECTION 4. PAYMENT DETAILS |
Pay to: |
Totalnannies.com |
Payment for: |
Agency Fee for language
course and accommodation
abroad |
Quantity: |
1 |
Amount: |
£ 99.00 |
Payment for: |
Registration
Fee |
Amount |
£ 43.00 |
Total to be
debited to credit card |
£142.00 |
ENTER YOUR CREDIT CARD INFORMATION
Your information will be kept secure and private
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First Name* |
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Last Name* |
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Type of Credit
Card* |
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Credit Card
Number* |
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Issue Number
(only Switch Cards) |
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Expiration
Date* |
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Billing Address
Street* |
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Billing Address
City* |
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Billing Address
County/State* |
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Billing Address
Postal Code/Zip* |
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Billing Address
Country* |
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For your protection, we
confirm credit card billing addresses.
The process normally takes
about 30 seconds, but it may take
longer during certain times
of the day. Please DO NOT cancel
your submit request until you
have received a final response
from the server.
By clicking "Continue", I
agree to be bound by
totalnannies.com's conditions
Conditions
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