AUSTRALIA ENGLISH INSTITUTE
ENROLMENT FORM
Please complete this form and return to us by email at
1 PERSONAL DETAILS
Title: / Mr / Mrs / Miss / Ms / Dr / OtherFamily Name:
Given Names:
Address: Post Code:
Phone Numbers: Home Work Mobile
Email:
Date of Birth Gender:
2 COURSE DETAILS
Name of course:
Preferred start date:
Indicate days/times you are available for your training sessions:
3 EMPLOYMENT DETAILS (if applicable)
Contact Name:
Business Name:
Address:
Town/Suburb Telephone:
4 LANGUAGE
Country of Birth: :
First Language: Other languages: :
5 STUDY REASON
Please outline your language concerns, language goals, or reason for completing this course.
Course payment information – page 2
COURSE PAYMENT
Refer to terms & conditions regarding payment information (http://www.australiaenglish.com/bookings/terms-and-conditions/)
Payment amount: $ ______(course cost + 10% gst)
Do you require a tax invoice?
Yes / NoPlease provide your ABN if Yes
Payment can be made in either of the following ways:-
Bank Transfer
To make a payment by internet transfer from your bank account, please use the following details:-
Payee:Australia English Institute
Bank: Commonwealth Bank of Australia
BSB Number: 064-138
Account Number: 1059 7772
Please use your name as reference
Credit Card
Type (select): / Visa / M/card / AmexNote: 1.5% fee for payments made by Mastercard / Visa. 3% fee for payments made by American Express
Credit Card number:
Expiry date:
Card holder name:
Address:
Town/Suburb Telephone:
Total amount:
I authorise Australia English Institute to debit my credit card with the amount shown above.
I certify that I am over 18 years of age.
Signature
Signed: Date:
(for authorization by email, please insert your email address)
Thank you for your enrolment. We look forward to meeting you on your training day
Office use only
Date Rec’d / Training Coordinator / Entered into database / Course Code / Course ID / Confirmed enrolment / Invoiced / Pre-course info sentAustralia English Institute 01/06/2014