SECTION
1. PERSONAL DETAILS
INSTRUCTIONS
Fill in the application form on-line. Please
answer all
questions. All fields marked with a
* are required and must be completed.
If you require a transfer from the airport
provide complete
flight details if you have them, otherwise
send them as soon as
possible.
Once your application has been received you
will be given a
Ref N° that you will
need to quote on all correspondence,
e-mails or when
contacting us by telephone. We will also send you confirmation of
the booking and registration for the chosen course
and all details of
your accommodation in your host family.
We offer secure SSL on-line 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 payments over
the
phone , cheques
and bank transfers .
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)
-
I work for:
My position is:
I have worked for this company for:
Months/Years
The most important situations where I have to speak English are: *
In this course I need a lot of practice in: *
(to make multiple choices hold down the ctrl key)
Comprehension
Grammar
Reading
Speaking
Writing
The last English language course I attended was:
Hobbies/Interests: *
I have a degree/diploma/certificate in:
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
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? *
Date course starts: *
01
02
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31
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
2002
2003
Date Course ends: *
01
02
03
04
05
06
07
08
09
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31
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
2002
2003
Time of arrival:
How long have you been studying English:? *
Level of spoken English: *
Beginner
Fair
Good
Very Good
Level of written English: *
Beginner
Fair
Good
Very Good
I would like to
learn/improve my English for: *
Pleasure
Study
Travel
Work
Type
of course required: *
A
B
C
D
R
X
Y
Z
Special Courses
If you wish to register for an exam please state it here: *
No exam
Certificate of Advanced English
Cambridge First Certificate
Cambridge Preliminary
Cambridge Proficiency
Pitmans
T.O.E.F.L.
ACCOMMODATION
Do you require accommodation: *
Yes
No
Type of accommodation:
Host Family
Hostel
Hotel
With packed lunch:
Yes
No
Date of arrival:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
2002
2003
Date of departure:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
2002
2003
Do you require transfer from the airport:?
Yes
No
One way
Both ways
If airport transfer is required please let us have your arrival
details here: (If you do not have this information yet please let us
have it as soon as possible)
Flight N°:
Airline:
Airport of Departure:
Airport of Arrival:
Other useful
information: (allergies, particular diet etc)
How did you find our website? *
Please quote Ref N° if applicable:
SECTION 4. PAYMENT DETAILS
Pay to:
Totalnannies.com
Payment for:
Agency Fee for Language
Course and accommodation abroad
Amount:
£99.00
Payment for:
Booking Deposit (which will be deducted from the total cost of the
course)
Amount:
£80.00
Payment for:
Registration Fee
Amount:
£38.00
Total amount to be debited to credit card:
£217.00
ENTER YOUR CREDIT CARD
INFORMATION
Your information will be kept
secure and private
First Name *
Last Name *
Type of Credit
Card *
Mastercard
Visa
Switch
Credit Card
Number *
Issue Number
(only Switch Cards)
Expiration
Date *
01
02
03
04
05
06
07
08
09
10
11
12
2002
2003
2004
2005
2006
2007
2008
2009
2010
Billing Address
Street *
Billing Address
City *
Billing Address
County/State *
Billing Address
Postal Code/Zip *
Billing Address
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
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have received a final response
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