Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

Language

Arabic Chinese (Mandarin) Chinese (Cantonese) English French German Italian Japanese Portuguese Russian Spanish Thai Other

Level/Ability

Beginner (little or no knowledge of language) Advanced Beginner (able to travel in the country) Low Intermediate (able to travel comfortably in the country) Intermediate (able to study & live in the country) High Intermediate (able to work in the country) Advanced (near fluent, able to work and function easily in the country) Professional (Fluent, able to read, speak & write near native level)

Class Type

Private Semi-Private (2-3 students) Small Group (3-6 students) Onsite Private Onsite Group

Class Hours

12 hours 5 hours (private) 10 hours (private) 20 hours (private) 24 hours 40 hours (private)

Start Date

-- mm/dd/yy

Availability

Saturday Morning Only (8:30-1pm) Any Day or Any Time Weekday Mornings (Monday-Friday) (best rate) Weekday Afternoon (Monday-Friday) Weekday Evenings (after 6pm) (Monday-Thursday)

BILLING

You are not required to fill out this portion of the form.  However, we only guarantee a reserved seat in our classes after payment has been received.  Also, payment must be received by the day before your first class. 

Credit Card

VISA MasterCard American Express Discover

Cardholder Name

Card Number

Expiration Date