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Language Course Application Form

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SUMMARY


 

 

  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 

 

 

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.

 

First Name*

Last Name*

D.o.B.*

Age:*

Gender:*

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*

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:

Next of kin Tel N: (country code first)

-

Marital Status*

Present Employment:*

What is your mother tongue?*

Do you speak any foreign languages?

Nationality:*

Do you: Smoke?*

 

Choice of country:*

Choice of city:*

Date course starts:*

Date Course ends:*

N of weeks required:*

Course N:

Type of course required:

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

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

  SECTION 2. ACCOMMODATION

Choice of Accommodation:*

In a private home:

Single Room Double Room:

 

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)

Do your intend to travel by car? (parking cannot be guaranteed):*

 

  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:

 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

First Name*

Last Name*

Type of Credit Card*

Credit Card Number*

Issue Number (only Switch Cards)

Expiration Date*

Billing Address Street*

Billing Address City*

Billing Address County/State*

Billing Address Postal Code/Zip*

Billing Address Country*

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

 

 

Great Britian

France

 

Germany

Ireland

 

Italy

 

 

 

Great Britain

France

 

Germany

Ireland

 

Italy

 

Spain

Switzerland

 

USA

Japan

 

 

 

Spain

Switzerland

 

USA

Japan

 

 

 

totalnannies.com privacy policy comments disclaimer last updated 24/10/2013 06:58:27   .

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