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Request for accommodation and language course in Dublin

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SECTION 1. PERSONAL DETAILS

 

INSTRUCTIONS

 

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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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If you require a transfer from the airport provide complete

flight details if you have them, otherwise send them as soon as

possible.

 

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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:*

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)

-

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)

The last English language course I attended was:

Hobbies/Interests:*

I have a degree/diploma/certificate in:

What is your mother tongue?*

Nationality:*

Do you: Smoke?*

Date course starts:*

Date Course ends:*

Time of arrival:

How long have you been studying English:?*

Level of spoken English:*

Level of written English:*

I would like to learn/improve my English for:*

Type of course required:*

If you wish to register for an exam please state it here:*

ACCOMMODATION

Do you require accommodation:*

Type of accommodation:

With packed lunch:

Date of arrival:

Date of departure:

Do you require transfer from the airport:?

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*

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

 

 

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Spain

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USA

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