family name * given name(s) * date of birth month/day/year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005     age * male/female * male       female       home address * phone * fax email * passport number nationality * name of emergency contact phone level of english beginner       elementary       intermediate       advanced       course starting date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005200620072008     course length (weeks) airport meet & greet yes, one way       yes, two ways       no       insurance: *all students must provide proof of insurance for the duration of their course (a) please arrange the Uni-Care travel and medical insurance NZ protector plan (b) please arrange the Uni-Care travel and medical insurance NZ premier plan (c ) I will arrange my own insurance 日本語 français 中文 español 한국어 portuguese     deutsch         communication english 12 weeks Only $3,600.00    application form ISO9001:2000 Registered