ESL Online Registration Form Please complete the form as best you can and press the "Submit" button. An ESL representative will contact you as soon as possible. If you prefer to register via mail or fax, just print this application form and send it to the address or fax number on the form! Interlangues International English (ESL) Department: 130 Albert St. Suite 710 Ottawa, Ontario, Canada K1P 5G4 Fax: 613-230-2047 eMail: International@interlangues.ca Personal Information Name  Permanent address  Date of birth  Home phone number  Office phone number  Fax number  Email  Occupation  Gender  Male Female Travel Information Date of arrival  Time  Carrier  Flight No.  Do you wish to be met at the airport?  No  Yes Course Information Start date  End date  Your current English ability is:  Minimal  Basic  Intermediate  Advanced Accommodation Do you require Homestay accommodation?:  No  Yes Number of weeks  Roommate's name  Allergies to pets?  No Yes Food allergies? (specify)  Smoke-free homestay?  Yes please I am OK with smoking Additional information  Please type here any additional information you feel we should know about your Homestay requirements. Health Insurance Health insurance IS MANDATORY when studying at Interlangues Language School. Health insurance can be acquired/bought directly from the school. The school uses student guard health insurance. Yes wish to purchase insurance No  Yes. Full name: Date of birth: Address in home country: Start date: Length of stay: For students who whish to acquire their health insurance elsewhere please specify below who your insurance is with. Name of insurance company Policy number I certify that the above information is correct.     * When pressing the Submit button, your form is sent as an email attachement. Click "OK" if you receive a warning message from your browser.

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