Application Form

This form may also be completed and printed for later facsimile or parcel delivery.
Please complete all information on this form. All fields in red are required.

Last Name:
First Name:
Sex: Male Female
Occupation:
Date of Birth:
Describe Your Level of English:
Beginner
Intermediate
Advanced
Pre-Intermediate
Upper-Intermediate
Home address:
(in your country)
City:
State/Province:
Zip/Postal Code:
Country:
Email Address:
Home Telephone:
(Please don't forget Country and City code)
Business Telephone:
(Please don't forget Country and City code)
Fax:
(Please don't forget Country and City code)
You know The Language Academy from:
Agent
Yellow pages
Internet
Magazine
Other Student
Other (please specify)
I will be studying (Please mark appropriate box)
General English - GEA1
General Intensive-GEB
Executive English
Executive Plus
Super Executive
Private Lessons
Teacher Training
General English GEC
(group + 5 private lessons)
General English- GED
(group + 10 private lessons)
TOEIC preparation
TOEFL preparation
Cambridge FCE preparation
Cambridge CAE preparation
Start Date of my course:
(month/day/year)
Number of weeks:
I wish to apply for a student visa:
  Yes No
Accommodations
I would like The Language Academy to arrange my housing:
  Yes No
Accommodation choices:
Homestay
Private Room
Shared Room
Hotel
Budget*
Standard**
Deluxe***
Deluxe Oceanside****
Apartment
Efficiency
Apartment
 

The Language Academy
The Language Academy - 200 South Andrews Avenue, Suite 401. Fort Lauderdale, FL 33301
Phone: 954.462.8373, Fax: 954.462.3738 Email: english@languageacademy.com