Starting Date  *

Number of weeks  *

Lessons per week

Name  *

Surname  *

Gender  *  Male   Female 

Street  *

Postal Code  *

City  *

Country  *

DateOfBirth  *

Profession

Home telephone  *

Mobile Phone

Fax

Work telephone

Email address  *

Airport transfer  * Arrival and departure  Arrival only  Departure only  None 

If yes, arrival airport

Arrival date

Arrival time

Company flight nº

Knowledge of Spanish  * Beginner  Elementary  Pre-intermediate  Intermediate  Upper-intermediate  Advanced 

Accommodation  * None  Shared flat, single room  Shared flat, double room  Family, single room, half board  Family, single room, full board  Family, double room, half board  Family, double room, full board  Private Apartment 

Where did you learn about La Janda  * Former student  Representative in my country  Google  Other search engine  My teacher  School / University  Advertisement  Other 

If other, please specify

Comments

Payment Type  * Credit Card: Visa  Credit Card: Mastercard  Bank Transfer 

Card Number

Card Expiry Date (Month) 01  02  03  04  05  06  07  08  09  10  11  12 

Expiry Date (Year) 2009  2010  2011  2012  2013  2014  2015  2016  2017  2018  2019  2020  2021 

Terms and Conditions  *  I agree with the terms and conditions