Maisons des Associations 12 Cours Fénelon 24 000 Périgueux FRANCE

Tél/Fax : + 33 (0) 553 35 31 07 Cel : + 33 (0) 06 89 05 00 53 APPLICATION FORM 2

Surname (Mr/Mrs/Miss/Ms) ………………………………………………………………………… First Name ………………………………………………………………………………………………… Nationality…………………………… Passport Number……………………………………… Date of birth …………… / …………… / ……………… Male Female

Marital status :

Single Married

Insurance : ……………………………………………………………………………………………… Person to be contacted in case of emergency : ……………………………………… Home adress :

…………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… Phone ……………………………………………… Fax ………………………………………………… E-mail ………………………………………………………………………………………………………… I have never learned French I have already some knowledge of French . Do you smoke?

Yes

/

no

. Health problems, allergy, special diet :

………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… . Have you ever been to France? . If you have, in which part of France :

Yes

/

no

………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………

. What do you expect from your stay ?

………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Fees Registration Lessons + Accomodation Total amount 50 % down payment

50 € ……………………………………………… ……………………………………………… ………………………………………………

Mode of payment

Postal order

or

cheque

Any bank charge is payable by the student. On receiving your registration forms and the down payment, we will send you a confirmation form. All the details concerning your stay will be stated as well. I want the confirmation of my stay sent to me by : Mail

Fax

E-Mail

I have read and I accept the above conditions stated by “Association Périgord Linguistique et Culturel”. Date : ……………………………………………

Printed fill this form Mail il to APLC Maison des Associations 12 cours Fénelon 24000 Périgueux FRANCE

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