NIK-LAS Registration Form

REGISTRATION FORM 2007-08

Personal Data
Name: * Surname: *
Date of Birth: Nationality:
Profession: Sex: Male Female
Address: *
City: * State/Province:
Postal Code: *
Country: *
Home Telephone: Work Telephone:
Mobile Telephone: Fax:
Email Address: *
Passport Type: Passport No.:
How did you learn about us:
Program #1

Language Level:
Course Start Date: No. of Weeks:
Accommodations:
Accommodations Start Date: No. of Weeks:
Program #2(Only complete if combining cities or programs)

Language Level:
Course Start Date: No. of Weeks:
Accommodations:
Accommodations Start Date: No. of Weeks:
Program #3(Only complete if combining cities or programs)

Language Level:
Course Start Date: No. of Weeks:
Accommodations:
Accommodations Start Date: No. of Weeks:
Any Special Needs
Pick-Up Service None Pick-Up Drop-Off	Flight No: Airline Co: Arriving from which city:
Mobile Rental Service None Yes Cities:
Start Date: No. of Weeks:
For Payment of Deposit
Attached a copy of the Bank Transfer statement
Attached an International Money Order, Bank Check or Traveler's Check Payable in US currency

You have read and agreed to all conditions of the General Conditions and Payment Process relevant to this application. *

(*) Required Field