Online regular application form

Mandatory field (*)

Personal Data

Name*
Family Name*
Date of birthday*	year month day

Gender *

Male
Female

Nationality*
Native Language
Passport Number

Address
Postal Code
Country
Telephone
Fax
E-mail*

Contact in case of Emergency

Name
Family name
Relationship with student (mother, brother, friend,...)

Telephone
E-mail

Address
Postal Code
Country

Program

Intensive French Program*

Start date

Start date*

Accommodation

Accommodation*
First day Accommodation*	Open/close calendar
Last day Accommodation*	Open/close calendar

Only for Homestay request

Are you allergic?	yes no
If affirmative, please specify

Are you vegetarian

yes
no

Do you take medications?	yes no
If affirmative, please specify

Do you like children?

yes
no
no preference

Do you like pets?

yes
no
no preference

Would you like to stay at a smoker's homestay?

yes
no

Let us know more about you, describe to us your hobbies and preferences :

Airport Pick up and Drop Off

Airport Pick up and Drop Off*
Flight Arrival Details: (if you don't have them right now you can send them later to our e-mail: e-mail info@edu-inter.net)
Day*
Hour*
Airport*
Airline*
Flight arrival from*
Flight Number*

Medical Insurance

Medical Insurance*
Arrival day*	Open/close calendar
Departure day*	Open/close calendar

Other

Are your doing your registration through an agency?*	Yes No
If yes, name of the agence

Application Submission
I hereby certify that the above information is true and complete. I have read and understand the program costs and the Edu-inter Refund Policy.