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.

Course parameters
Course type
Individual
Group
Interpreter
4
6
other
Intensive
Superintensive
hours per day for
1
2
3
4
4+

one
week
weeks
in 2010 starting in
on the
11th
25th
08th
22nd
08th
22nd
06th
19th
03rd
17th
31st
14th
28th
12th
26th
09th
23rd
06th
20th
04th
18th
02nd
15th
29th
no date available
.
Italia da toccare (optional) Select In Touch with Italy program number/s:
1 2a 3 4 5a 6 7a
2b 5b 7b
Accomodation Please, arrange the following accomodation for me:
In family
In hotel
single
double
with
breakfast
half board
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 di Roma S.p.A. - Agenzia di Livorno Cogorano
Via Cogorano 3/17 - Livorno
IBAN: IT51P0300213905000002173916 - BIC SWIFT: BROMITR1DD9
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 ________