Personal Information Full Name (as in passport) * Email * Confirm Email * Gender Male FemaleDate of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Month January February March April May June July August September October November December /Nationality Student Address
Student Phone Student Fax
*Required Fields Emergency Contact Emergency Contact Name Emergency Contact Phone Agency Agency Name Agency Phone Agency Fax Program of Study Requested Program * -----Select One----- English for Everyday Life English for Business High School Credits Other If "Other", what kind of program would you like to study at KIOSK? Number of weeks requested 4 8 12 16 20 24 28 32 36 40 44 48 52 Number of hours per week 15 20 25 Level of English knowledge Beginner Low Intermediate High Intermediate Advanced Start Date (Monday) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Month January February March April May June July August September October November December /Year 2011 2012 2013 End Date (Friday) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Month January February March April May June July August September October November December /Year 2011 2012 2013 *Required Fields Health Insurance Health Insurance CDN$2.50 per day Number of days If "Health Insurance" is not checked, you must provide proof of health insurance if you do not wish to purchase it at KIOSK
Name of Insurance Company Airport Pickup Airport Pickup CDN$100 Airport Pickup and Drop-off CDN$150 No Airport Pickup Arrival Date Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Month January February March April May June July August September October November December /Year 2011 2012 2013 Arrival Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 : 00 05 10 15 20 25 30 35 40 45 50 55 Arrival Airline Arrival Flight Number Return Date Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /Month January February March April May June July August September October November December /Year 2011 2012 2013 Homestay Homestay CDN$850 for 4 weeks, includes 3 meals a day Residence CDN$510 for 4 weeks No Homestay Number of weeks 4 8 12 16 20 24 28 32 36 40 44 48 52 Are you allergic to pets? Yes No Do you have any other allergies? Yes NoWhat kind? Do you smoke? Yes NoAre smokers in the house OK? Yes NoAre you a vegetarian? Yes NoSpecial diet needs Payment Details - KIOSK will contact you with your final quote Registration Fee CDN$ Tuition Fee CDN$ Materials Fee CDN$ Homestay Service Fee CDN$ Homestay CDN$ Airport Pickup Fee CDN$ Health Insurance CDN$ Total Payment CDN$ This is an estimate of the total payment to be made and may be different from the invoice amount
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Toronto-Dominion Bank, Village Centre 65 Wellesley St. East, Toronto, Ontario, Canada, M4Y 1G7 Account Name: KIOSK School of English Account Number: 12205003859 Transit: 12202 004 ABA Number: ABA 026 009 593 Swift Code: TDOMCATTTOR
Mail an International Money Order in US$ or CDN$ to:
KIOSK Language Centre 65 Wellesley Street East, Suite 200, Toronto, Ontario, Canada, M4Y 1G7
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