54 Merrion Square

Dublin 2, Rep. of Ireland

T: + 353 1 661 3788

F: + 353 1 661 5200

E: info@englishindublin.ie

W:www.englishindublin.ie

 

                                              

ID No.

 

                                   _________                 

 

 

Personal Details

 

First Name:____________________ Family Name:____________________ Nationality:_____________

 

Male £ Female £   Date of Birth: __________   Passport No:______________ Visa required: Yes £  No £

 

Home Address: ________________________________________________________________________

 

Dublin Address: _______________________________________________________________________

 

Telephone: __________________ Fax:__________________ Email: _____________________________

 

Emergency Contact No.:______________ How did you hear about English in Dublin? _______________

 

Course Details

 

Course Name:______________________   Hrs per week:______   Level of English:_________________ 

 


Start Date:______________    Finish Date:______________   No. of Weeks:       

NOTE: Beginner and elementary students may be required to take a placement test before being accepted by the school

 

Accommodation Details

 

Host Family required: Yes £    No £   If yes, Single £  Twin £

NOTE: Choice of accommodation is dependent on availability

 


Start Date:______________                Finish Date:______________   No. of Weeks:       

 

Do you have any special requirements (Medical/Dietary/Allergies)?   Yes £ No £

If yes, please specify: ______________________________________________________

 

Do you require insurance? Yes £ No £

 

Arrival Details

 

Arrival Date:_________ Arrival Time:______ Flight No:_________ Arrival Transfer required: Yes £ No £

 

School Bank Account Details  

Bank Name and Address:         Bank of Ireland, Donnybrook, Dublin 4, Ireland

Account No: 7310 1806            Sort Code: 90-10-87   

Swift Code:  BOFIIE2D                       IBAN No: IE52 BOFI 9010 8773 1018 06 

 

ALL STUDENTS ARE REQUIRED TO HAVE A MINIMUM ATTENDANCE OF 80% FOR VISA RENEWALS

 

“I confirm that all the information I have supplied above is true and correct at this time. I understand that all monies paid are non-refundable and that credits will only be allowed at the discretion of the Directors of English in Dublin.  I fully accept I must achieve a minimum attendance of 80% for the duration of my course”

 

Signature: __________________________               Date: ________________   BRAZIL

NOTE: If the applicant is under 18 years of age, a parent’s or guardian’s signature is required on this enrolment form

 

FOR OFFICE USE ONLY

 

Level:   ______________   Time of Class: _______   Teacher: ______________   Passport copy: Y £  N £

 

Fees Paid: Tuition:___________ Accommodation:____________  Insurance:____________  Other:____________