Family name :
First name :
Date of birth :
Sex :
Nationality :
Occupation :
Street 1 :
Street 2 :
Post/Zip code :
Town :
State/Country :
Phone :
Fax :
Email address:
How did you hearabout Actilangue?
COURSE
I hereby enrol :
Course No 1 (4 less. daily)
Junior Programme (16-20)
Course No 2 (5 less. daily)
Course No 3 (6 less. daily)
Extra lessons DELF
Combination Course C25
Combination Course C30
Private Course E.I.20
Private Course E.I.40
Private Course E.I.25
Private Course E.I.50
Private Course E.I.30
Date of the course :
Duration :
weeks
Promotion code :
ACCOMMODATION
I wish to live with a family :
Date of arrival :
Date of departure :
Transfers :
Time of arrival :
Yes
Flight/Train No :
No
I wish to live in the shared Villa-Apartment
I wish to live in the Flat/the Residence:
Number of person :
I wish to live in the apart'hotel:
I wish to live in the hotel :
I will have a car in Nice :
Knowledge of the French Language :
PAYMENT OF THE DEPOSIT (150 €)
Bank transfer for Actilangue :BNP PARIBAS, NiceAccount No : 000 151 114 62-85IBAN : FR76 3000 4000 3800 0151 1146 285BIC : BNPAFRPPNIC
Cheque (in EURO)
Postal order (cash)
Credit card (Visa/Mastercard)
Credit card No (without spaces):
Valid thru :
Last 3 numbers on the back of the card :
Card holder :
Comments :
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