Italian language school

Mr. Mrs. Ms.

First Name:

Surname:

Date of Birth:
Day: select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month: select January February March April May June July August September October November December Year:

Nationality:

Mother Tongue:

Profession/Studies:

Home Address (Street):

City:

Zip/Post Code:

Country:

Telephone (Home):

Telephone (Work):

Facsimile:

E-mail Address:

How did you hear about Centro Giacomo Puccinii? select from an ex-student through a friend from a travel agency from a colleague from an Embassy / Consulate from an Italian Culture Institute from a teacher in an advertisment found you on the www others

If you found us on the Internet please specify where:

If 'others' or 'via an agency' please specify:

Why did you choose Centro Giacomo Puccini?

COURSES:

Course 1: I wish to enroll in the following course:

select Standard Course Intensive Plus 5 Course Intensive Plus 10 Course Private Tuition carnival week academic school year culinary arts for professionals professional courses Italian for senior long term standard long term semester long term CSN course Examination Course "Firenze" AIL-DELI A2 Examination Course "Firenze" AIL-DILI B1 Examination Course "Firenze" AIL-DILC B1 Examination Course "Firenze" AIL-DILI B2 Examination Course "Firenze" AIL-DALI C1 Examination Course "Firenze" AIL-DALC C1

Starting Date :	Day: select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Month: select January February March April May June July August September October November December	Year:
Number of weeks:

Course 2: I wish to enroll in the following course:

select Standard Course Intensive Plus 5 Course Intensive Plus 10 Course Private Tuition carnival week academic school year culinary arts for professionals professional courses Italian for senior long term standard long term semester long term CSN course Examination Course "Firenze" AIL-DELI A2 Examination Course "Firenze" AIL-DILI B1 Examination Course "Firenze" AIL-DILC B1 Examination Course "Firenze" AIL-DILI B2 Examination Course "Firenze" AIL-DALI C1 Examination Course "Firenze" AIL-DALC C1

Starting Date :	Day: select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Month: select January February March April May June July August September October November December	Year:
Number of weeks:

MY KNOWLEDGE OF ITALIAN:

Have you already studied Italian?

No Yes

If 'Yes' please complete the following:

University/School:

Street:

Zip/Post Code:

City:

Name of your Teacher:

Self evaluation:    select absolute beginner beginner with previous study of italian basic low intermediate high intermediate advanced

MY ACCOMMODATION:

I wish the school to provide my accomodation:

No Yes

If 'Yes' please complete the following:

Apartment	Room type:
	Single Room
	Double Room
Hotel*, breakfast	Room type:
	Single Room	breakfast half-board
	Double Room
Hotel**, breakfast	Room type:	breakfast half-board
	Single Room
	Double Room

Others, please give details

Do you smoke?	No	Yes
Do you have any allergies?	No	Yes
if yes please give details
Do you need a special diet?	No	Yes
if yes please give details

Do you need a transfer? No Yes
If 'Yes' please give details:    Arrival date: day month year

Arrival time:	select am pm
Arrival location:
Flight Number:
Train Number:

Special requests/observations:

PAYMENT:

Note that if you are registering more than 30 days before the beginning of the course, we require a deposit payment of 70 Euro. If you prefer, you can also pay the total course fees at once.

If you are registering less than 30 days before the beginning of the course, we require the payment for the total course fees.

I have already paid the amount of EURO by means of:

Cheque internacional
Orden de Pago Postal
Bank transfer

To: centro culturale g. puccini srl
Bank: intesa sanpaolo (P.zza M.D’azaglio, 44 IT-55049 Viareggio (LU), tel +39 0584 325711)
sban: IT71 I030 6924 8000 7810 9260 124
swift: BCITITMM

My registration implies the acceptance of the "Terms and Conditions of participation" as mentioned in our Web site or brochure.

Place and date: