Language Course Application Form for Annecy

Language Course Application Form

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SUMMARY

SECTION 1. PERSONAL DETAILS

Fill in the application form on-line. Please answer all

questions. All fields marked with an * are required and

must be completed

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*

Date of Birth*

Place of Birth

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)

Nationality:*

What is your mother tongue?*

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

Do you: smoke?*

Date of arrival:*

Date of departure:*

Language course required:

Sporting activities required (to make multiple choices hold down the ctrl key)

Other useful information: (allergies, particular diet etc)

SECTION 2. ACCOMMODATION

Choice of Accommodation:*

Host Family: Hotel: Residence:

SECTION 4. PAYMENT DETAILS

Pay to:

Totalnannies.com

Payment for:

Agency Fee for language

course and accommodation

abroad

Quantity:

Amount:

£99.00

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.


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