Important Instructions:

Fill this form out completely. Only "In Touch with Italy" is optional.
Print out a copy for Agorà and a copy for yourself.
Select the "Send enrolment form" button at the bottom of this form.
Sign one copy and send it to CLA by Fax or regular post.

Enrolment Form for Adults

Personal information

Name

First name

Middle name

Last name

Address

Number	Street
City	Postal code
Country

Other contact information

Home phone	Work phone
Cell phone	E-mail address

Birth data

Date of birth

Gender
Female Male

Birthplace City

Country

Course information

How would you rate your knowledge of Italian? None Some Average Good Fluent

I would like to enrol in the following course.

Payment I have paid an advance of euros, equal to 50% of the total course fees, by bank transfer in the name of:

Centro Linguistico Agorà
Unicredit Banca - Agenzia di Livorno
Via Cogorano 3/17 - Livorno
IBAN: IT82C0200813905000002173916 - SWIFT: UNCRITB1DD9

Comments Please, inform us of any particular dietary, medical, or other pertinent conditions or needs, as well as other information you feel should be included.

How did you hear about Centro Linguistico Agorà?

Privacy of information I, the undersigned, do hereby Centro Linguistico Agorà to use my personal information accoring to the spirit and effects of Law 675/96.

Acceptance I accept the general conditions for courses in Italian as a Second Language at Centro Lingusitico Agorà.

Signature ____________________________________ Date ________

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

m
e
n
u

1	2a	3	4	5a	6	7a
	2b			5b		7b