Explorers Academy

APPLICATION FORM
Please complete and submit or fax to: (+44) 709 208 7367
See application guidelines and conditions.

Please enter your email address:
Verify your email address:          

- Course or program title
- Starting date
- Duration

- Alternative course
- Alternative starting date
- Duration
Please indicate alternative course, if possible, so that we can secure a place in case your first choice is fully booked.

- Surname
- First name(s)
- Address
-City
- Postal code or zip
- Country
- Telephone
- Fax, if applicable
- Email address

- Nationality
- Date of birth
- Occupation

Employment record:

Enter employer , position, periods

Travel experience:

Enter countries, periods

Education:

Enter School or course, Subject and Period

Language skills:

Leisure interests:

Comments or remarks, if any:

I certify that the above information is correct, and I have read, understood and accepted the Explorers Academy conditions.

Print 2 copies of the completed form. Click "Submit" and wait for reply. If your placement is confirmed, complete the date, sign and fax the form or send one copy of the application by post to Explorers Academy, Liaison office at Village Catalan, F-66820 Vernet-les-Bains, France with your payment.

Date: Signature: _________________________________________

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