|
| Family
Name |
|
| Given
Names |
|
| Gender |
|
| Date
of Birth (dd/mm/yyyy) |
|
| Nationality |
|
| Address
/ Home Country |
|
| Phone
Number (Incl. Country Code) |
|
| Fax
Number (Incl. Country Code) |
|
| E-mail Address |
|
| Type
of VISA |
Visitor / Holiday
Student
Working Holiday
|
| Passport
Number |
|
| ACCOMMODATION
REQUEST |
| Do
you require Homestay Accommodation? |
No |
| Date
to Join |
|
| Number
of Weeks |
|
| Do
you have any special requests? Food,Allergies,Smoke,Pets,Children,etc. |
|
| AIRPORT
PICK-UP AND RETURN |
| Do
you require Airport Pick Up Service? |
Yes(Brisbane Airport)
Yes(Gold Coast Airport)
No |
| Flight
number |
|
| Arrival
Time |
|
| Date
(dd/mm/yyyy) |
|
|
Yes(Brisbane Airport)
Yes(Gold Coast Airport)
No |
| Flight
number |
|
| Departure
Time |
|
|
|
| COURSE
SELECTION |
| (ELICOS) |
| |
| |
| (NON ELICOS) |
|
| |
|
| Number of Weeks
|
|
| Start Date
(dd/mm/yyyy) |
|
| Finish Date
(dd/mm/yyyy) |
|
| DECLARATION |
I
certify that information and the details I
provide on this form are true and correct.
I have read and accepted the HIAGC's Conditions
of Enrolment and Refund Policy. |
|
|
| Signature (Type your Full
Name) |
|
| ** If submitting on-line,
typing your Full-Name and clicking the "Submit
Enrolment" button assumes that you have
made this declaration. |
| Date
(dd/mm/yyyy) |
|
|
|
|
|
|
|
|
|
|
