Please print and fax your completed form to (441) 236-9317

COURSE APPLICATION FORM

Please complete clearly

Surname

First names

Address

Telephone

Fax

E-mail

Date of Birth

Nationality

Occupation

Hobbies

Sports

Personal preferences	Accommodation preference (if assistance is needed)
I am a smoker
I am a non-smoker	Self-catering
I am allergic to cats	Guest House
I am not allergic to cats	Hotel
I am allergic to dogs	Meals: breakfast only
I am not allergic to dogs	Meals: breakfast & evening

Please indicate your level of
Written English	Spoken English
Complete Beginner	None
Elementary	Very Little
Intermediate	Elementary
Advanced	Good
	Very Good
	Advanced

Course Preference:	Course Programme:
General English	One-to-One One-to-Two
Business English	One-to-Three One-to-Four
Combination General & Business	One-to-Five
Other (eg, Medical, Technical)	Hours per Week:
Please specify:	15 20 25 30 35
	Morning classes*
	Afternoon classes*
	*For 15-20 hours per week ONLY

Date You Wish to Begin:	TOTAL FEES DUE:
Day Month Year	US $

	CHOICE OF PAYMENT:
Single payment in full:	Deposit (US $500)	Balance of Payment
Bank Draft	Bank Draft	Bank Draft
Bank Transfer	Bank Transfer	Bank Transfer
Visa	Visa	Visa
MasterCard	MasterCard	MasterCard

I understand & agree to the conditions of enrolment & confirm above details are correct.

Signature:

Date:

DESTINATION BERMUDA

PLANNING YOUR COURSE

TUITION FEES

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Maureen Anderson <andiec@ibl.bm>