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SECTION
1. PERSONAL DETAILS
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Print out the application form, fill it in
. 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 |
  
For your convenience if you prefer, you
can send us your application form securely on-line. We also accept
cheques and
bank transfers. |
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First Name*
Last Name*
Date of Birth*
Place of Birth
Age:*
Gender:* |
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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 |
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Address* |
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Next
of kin Address: (if different from above) |
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Next of kin Tel N°
:(country
code first) |
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Nationality:* |
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What is your
mother tongue?* |
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How
do your rate your current level of the language?*
(please tick)
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Do you: smoke?*
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Date of arrival:* |
Date of departure:* |
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Language course required:
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Sporting activities required (please tick)
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Horse riding: |
Sailing: |
Skiing: |
Tennis: |
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Other useful
information: (allergies, particular diet etc)
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SECTION 2. ACCOMMODATION |
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Choice of Accommodation:*
(please tick)
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Host Family: |
Hotel: |
Residence: |
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SECTION 4. PAYMENT DETAILS |
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Pay to: |
Totalnannies.com |
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Payment for: |
Agency Fee for language
course and accommodation
abroad |
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Quantity: |
1 |
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Amount: |
£99.00 |
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I wish to pay for the registration fee by (please tick) |
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Bank Transfer: Cheque:
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Signed: |
Date: |
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