Axion 21 - Centre Linguistique International

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Important Information: «Your application cannot be submitted without the entry required in boxes
marked with an asterisk (*)»
REGISTER
ENGLISH IMMERSION PROGRAM
FRENCH IMMERSION PROGRAM
START DATE*
ENGLISH EVENING PROGRAM (18:00 - 21:00)
FRENCH EVENING PROGRAM (18:00 - 21:00)
SPANISH EVENING PROGRAM (18:00 - 21:00)

TEF/TOEFL /TOEIC /GMAT
LENGTH OF STAY WEEKS

PERSONAL DATA
LAST NAME *
NAME *
GENDER MALE
FEMALE
DATE OF BIRTH
CITIZENSHIP
NATIVE LANGUAGE
HIGHEST LEVEL OF EDUCATION COMPLETED
INSTITUTION

HOW DO YOU RATE YOUR ENGLISH/FRENCH ABILITY?
BEGINNER INTERMEDIATE ADVANCED

HAVE YOU TAKEN?
TOEFL:
NON
OUI
SCORE
TOEIC:
NON
OUI
SCORE

HOW DID YOU HEAR ABOUT AXION 21 LANGUAGE SCHOOL ?


CONTACT INFORMATION
ADRESS
CITY
POSTAL CODE
EMERGENCY CONTACT
PHONE
FAX
EMAIL *

ACCOMMODATION
DO YOU NEED HOMESTAY?
(4 weeks minimum)		 YES NO
IF YES :        
DO YOU SMOKE ? YES NO
CAN YOU LIVE WITH SMALL CHILDREN ? YES NO
CAN YOU LIVE WITH PETS ? YES NO
CAN YOU LIVE WITH SMOKERS ? YES NO
DO YOU HAVE SPECIAL REQUESTS REGARDING FOOD ? YES NO

DO YOU NEED AIRPORT PICK-UP ? YES NO

FEES
BANK TRANSFER TO :
BANK OF MONTREAL
5145, CHEMIN DE LA CÔTE-DES-NEIGES
MONTREAL, QUEBEC
H3T 1X8
ACCOUNT NUMBER : 01681-001-8900-166
SWIFT CODE : BOFMCAM 2
AN INVOICE WILL BE ISSUED UPON RECEIPT OF YOUR APPLICATION FORM
INTERNAL RULES
PLEASE READ AXION 21 INTERNAL RULES
FORM SUBMISSION
BY SENDING THIS FORM, YOU WILL ACKNOWLEDGE THE TERMS OF THIS CONTRAT

Important Information: «Your application cannot be submitted without the entry required in boxes
marked with an asterisk (*)»
PLEASE READ AXION 21 INTERNAL RULES BEFORE SUBMITTING THIS FORM!