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Enrolment Form Actilangue

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 hear
about 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

Date of arrival :

Date of departure :

I wish to live in the Flat/the Residence:

Number of person :

Date of arrival :

Date of departure :

I wish to live in the apart'hotel: 

Number of person :

Date of arrival :

Date of departure :

I wish to live in the hotel : 

Date of arrival :

Date of departure :

I will have a car in Nice :

Yes

No

Knowledge of the French Language :

PAYMENT OF THE DEPOSIT (150 €)

Bank transfer for Actilangue :
BNP PARIBAS, Nice
Account No : 000 151 114 62-85
IBAN : FR76 3000 4000 3800 0151 1146 285
BIC : 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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