ESI Language Centers - Bangkok

Personal Detail

Mrs. Ms. Mr.

First Name:		Family Name:
Date of birth (dd-mm-yyyy):		Place of birth:
Nationality:		Email:
Profession/Studies:		Passport number:

Home address:

City:		Postal Code:
Country:		Phone (Home):
Phone (Mobile):		Fax:

In case of emergency please inform:
I wish to enroll at the ESI Language Centers in:	Bangkok
I found out about the ESI Language Centers through:

Enrollment Detail

I wish to enroll in the following courses:

Course No	Course Title	Start Date(dd-mm-yy)			Total Weeks
			-	-
			-	-
			-	-

We'll contact you of your prefer payment by:

Bank/Post/Cheque Credit Card

Payment: Note that if you are registering more than 21 days before the beginning of the course, we require the payment of the registration fee of US$75 (US Dollar Seventy Five). If you prefer, you can also pay the total course fees at once. If you are registering less than 21 days before the beginning of the course, we require the payment for the total course fees.

I have read the "General Conditions of Participation" and hereby declare my acceptance: