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Your Name *

First Name Last Name

Date of birth *

- Month - Day Year

Are you currently studying? *

Yes No

What is the name of your school?

Select your Country of residence *

Select your country of Nationality *

Your E-mail Address *

Alternative E-mai Address

Phone Number *

- Area Code Phone Number

Skype ID

Would you like us to contact you..? *

By phone By mail By skype

What language would you like to learn? *

Please note that you can only study English in Montreal. French courses are available in both cities

In which school would you like to study? *

Montreal Quebec Both

How many weeks would you like to study? *

When would you like to start your course? (Approximate date) *

Month Day Year

What kind or program would you like to take? *

	Part-time (18 lessons)	Full time (24 lessons)	Intensive (30 lessons)	Super Intensive (35 lessons)
Type of program

Do you need accommodation? *

Yes No

What kind of accommodation?

	Homestay (3 meals a day)	Homestay (2 meals a day)	Homestay (0 meals a day)	Student's residence	Hostel	Studio	Furnished appartment
Select your type of accommodation

Do you require airport pick-up? *

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Do you require airport drop-off? *

Yes No

Do you require medical insurance? *

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How did you hear about us? *

Agent Google Facebook Recommendation Information in my school Languages Canada Other

Agency name

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