a) Surname

b) First name

c) Nationality

d) Passport number

e) Mother tongue

f) Date of birth

g) Sex: [ ] Male [ ] Female

h) Address

i) Country

j) Occupation

k) Telephone

l) Mobile phone

m) E-mail

n) Fax

Level of Spanish [ ] Beginner [ ] Elementary [ ] Intermediate [ ] Advanced


COURSES

Please reserve me a place on the following course(s)

1. Group intensive course - dates - from to

2. Combined course - dates - from to

3. One to one private classes - dates - from to

4. Spanish for business course - dates - from to

5. Special interest seminars

• name of semininar(s)
• dates - from to
  

.

ACCOMMODATION

Exact accommodation dates
From (exact date of arrival and time) to (date of departure)

Host Family

Host Family - Individual Room
[ ] bed and breakfast
[ ] half board

Host Family - Individual Room executive
[ ] bed and breakfast
[ ] half board

Host Family - Double Room
[ ] bed and breakfast
[ ] half board

Vila Univeritària residence
[ 2 bed flat
[ ] 4 bed flat
[ ] 5 bed flat

Residence Campus del Mar
[ ] single room
[ ] twin room

Residence Ciutadella
[ ] single room
[ ] twin room

Residence Sarrià
[ ] single room
[ ] twin room

Shared private apartment
[ ] single room
[ ] twin room

Shared university flat
[ ] single room
[ ] twin room

Serhs Hotel Campus - 3 stars
[ ] double room

Hotel Sant Pau - 2 stars
[ ] double for single use
[ ] twin bed room

Comments/special requests


Please reserve my airport transfer on arriva
Date flight number and arrival time

Optional UAB Barcelona persona insurance for medical and personal property

[ ] yes [ ] no
.

Payment details/Forma de Pago

By Bank Transfer
I confirm payment of the required deposit of € 250 amount by: Bank transfer

Bank reference and date
Bank: Caixa Catalunya
Account name UAB Barcelona
Address: Plaça Cívica UAB, 08193 Cerdanyola del Vallès (Barcelona)
account number: 2013-0692-89-0201901437

By credit card
Credit card : [ ] Visa [ ] Mastercard

Name of holder

Number

Expiry date

Date


Signature

UAB Barcelona C / Sant Antoni Maria Claret 171 08041 Barcelona, Spain tel : (+34) 93 433 50 60 fax : (+34) 93 433 50 66 email : info@uab-barcelona.com .

.