Printable Internet
Application Form

FAX APPLICATION to

 Mr

 Ms

________________________________________________

First Name

________________________________________________

Family Name

 Single

 Married

Date of Birth:         /        /          ( DD / MM / YY )

Address in your country:

Address in Canada (if known):

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

Phone Number: _____________________

Phone Number: _____________________

FAX Number: _____________________

FAX Number: _____________________

EMAIL:

EMAIL:

I would like to register for:

 Intensive ESL Program

Specialized Studies (max 3 per course)

 Intensive ESL and Specialized Studies

 English for Business Management

 Part-time ESL (please check one below)

 English for Academic Preparation

          Integrated Skills

 Listening and Pronounciation

          Communication Skills

 TOEFL Examination Preparation

 English for Business Professionals

 TOEIC Examination Preparation

 English for University Preparation

 Executive English

 Evening Courses

 English Plus Activities

My English Level is:

 Beginner

 Intermediate

 Advanced

My Visa in Canada is:

 Student

 Visitor

 Working Visa

I will need a homestay:

 Yes

 No

I would like to start my homestay:         /        /         

Check-out Date:

         /        /         
 

Total Nights:

_______
 

I will need airport pickup:

 Yes

 No

Airline Flight #:

________

Arrival
Time:

_______

Arrival
Date:

         /        /         

Many Canadian families have pets:

Can you live with a cat?

 Yes

 No

Can you live with a dog?

 Yes

 No

Many Canadians are non-smoking:

Are you a smoker?

 Yes

 No

If you are a smoker, would you be willing to smoke outside?

 Yes

 No

Personal Characteristics:  Are you...

 Energetic

 Outgoing

 Reserved

 Quiet

 Shy

 Like spending time at home

 Sociable

 Enjoy a very social life

What family type do you prefer?

 Children

 Teenagers

 No Children

 No Preference

Do you have any allergies, special medication or health problems?

____________________________________________________________________________

Do you have a special request for your homestay?

____________________________________________________________________________

Emergency Contact Person >>>>>>>

Name: ______________________________________

Phone: ______________________________________

Your Signature

Today's Date

___________________________________

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