AM LANGUAGE

AGENT ENROLMENT FORM

This f orm is to be filled in and sent to A M Language together w i t h a passport copy and passport photo.
Student’s Personal Details (please ty p e t h e n a m e correctly, as it will appear o n your certificate)

*S u rnam e : Pereira Caetano *Name: Ana Isabella *Date of birth: 18/feb/2004 M

✔ F
*Nationality: Brazilian *Passport no: GE473841
*Address: Rua Franciso da Cunha - casa 272 *Tel: +55 81 997573068 *Mobile: +55 81 997573068
*E-mail: isabellapcaetano80@gmail.com
Student’s Emergency Contact Details (kindly give us details of a person w e are to co n ta ct in case of emergency)

S u r n a m e : Gomes Name: Ana Claudia Tel: +55 81 99844 7673

W h a t is t hi s person’s relation to y o u ? Mother E-mail:
Personal I n fo r m a tio n

Me di c al c o n d i t i o n s / al l e rg i e s / di e t r e q u i r e m e n t s /learning Disability/ physical disability :

Additio n a l I n fo r m a tio n

D o e s t h e s t u d e n t n e e d a Vi sa Invitation Le t t e r? YES N✔o

Does the student need Bildungsurlaub ? YES NO ✔ If ye s state R e g i o n (For G e r m a n s t u d e n t s only)

*Flight Details (if n o t yet available, kin dly send t h e m as soon as possible)

Date Time F lig h t n u m b e r A i r p o r t t r ansfer (delete a c c or dingly )

Arrival YES No

D e p a r tu r e YES No

Travel Insurance: D o you require insurance? YES ✔

/ NO

Course Details (kindly indicate t h e course you w o u l d like to follow)

* N a m e of course: Intensive English

*Course start date: 05/sep/2022 C o u r s e e n d date: 30/sep/2022

Comments:

C o u r s e B o o k will b e i n c l u d e d o n you r I nvoi c e – 3 5 E u ro

When level changes a new book needs to be bought.

*Acco m m o da tio n Details (kindly indicate X t h e ty p e of a c c o m m o d a t i o n you w o u l d like)

Accommodation Sharing r o o m Single r o o m Bed &Breakfast Half board Full board

Host Family

Executive Host Family

Shared a p a r tm e n ts (self-catering) N/A N/A N/A

Suite Shared A p a r t m e n t ✔ N/A NA NA

Hotel ***/****/***** (indicate your preference)

A c c o m m o d a t i o n start date:03/sep/2022 A c c o m m o d a t i o n e n d date: 02/oct/2022

Comments:

IMPORTANT: Pa y m e n t Details Please not e t h a t full p a y m e n t needs t o be settled m i n i m u m 2 weeks prior t o arrival.

Option 1
NOTE: D e p o s i t of 25% of t h e total a m o u n t n e e d s to b e se t t l e d w h e n q u o t a t i o n is re c e i ve d b y A M L a n g u a g e

O p tio n 2

NOTE: Total a m o u n t c a n b e se t t l e d w h e n s e n d i n g t h e b o o k i n g to A M L a n g u a g e
*Kindly n o t e t h a t a 5% s u r c h a r g e is a p p l i e d w h e n p a y i n g online
**Bank c h a r g e s are n o t i n c l u d e d i n t h e q u o t e d invoice. S t u d e n t n u m b e r s h o u l d b e re f e re nc e d i n t h e b a n k transfer details

Confirmation and Signature

✔ I agree to accept responsibility for all fees as indicated in the quotation that I received
✔ By signing this enrolment form, I have read, understood and accept the Policies & Guidelines of AM Language.

Bianca Cavalcanti 22 06 2022

Signature of applicant:_____________________________________ Date (DD/MM/YY): ______/______/_____

For m o r e details LICENSED BY CERTIFIED BY ACCREDITED BY

info@amlanguage.com
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Tel +356 21324242