AMERICAN SPANISH SCHOOL

APPLICATION FORM

Please fill out the below form and send a deposit through Western Union to Anibal Proaño O., Quito-Ecuador or a deposit to the the following account: Aníbal Proaño O., Bank: Produbanco, Swift code: SWIFT CODE: PRODECEQ, Av. Amazonas 3775 y Japon, Tel. (593 2) 2999000.

FULL NAME: DATE OF BIRTH: NATIONALITY:

PASSPORT NR: EMAIL: PROFESSION:

HOBBIES: TELEPHONE:

NR. OF WEEKS: Nr of weeks 2 4 5 6 7 8 9 10 HOURS PER DAY: Hours/day 4 5 6 7 8

STARTING DATE:   ENDING DATE:

KIND OF ACCOMMODATION: None Home stay Apartment Hotel FROM: TO:

DETAILS OF ARRIVAL:

DATE: TIME: FLIGHT NUMBER:

DO YOU WANT US TO PICK YOU UP? YES NO

MY LEVEL OF SPANISH KNOWLEDGE COULD BE: Beginner Intermediate Advanced    

WHICH OTHER LANGUAGE DO YOU SPEAK?

I AM MAKING A DEPOSIT OF No deposit US $50 US $100THROUGH No deposit Bank wire Western Union

SPECIAL REQUESTS OR REMARKS: