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:____________