Surname:            Name:

Date of Birth: (dd/mm/yyyy)

Male:             Female:

Nationality:

Address:  

City:                 Postal/zip code:

Country:  

Telephone                E-mail:

Have you taken our test?    yes    no          Parlitalia score:

If not what is your knowledge of Italian? None Minimal Good Very good

Select the Course/Courses you want to attend (more than one option is possible):

Group Course:     Individual Course:     Weekend Crash Course:

History of Art Seminars:       Cultural Programme:         Wine Tasting Classes:

Do you want Parlitalia to arrange your accommodation?  yes    no  

Select accommodation type: Farmstay Apartment Single room Double room Homestay Hotel

Special requirements (disability, smoking, pets):

Payment of Deposit: Bank transfer International bank cheque International money order Credit card through paypal

Any other information you would like to give us

Privacy clause. I authorise PARLiTALIA to use my personal details in accordance with art. 13 of the Italian law n. 675/96, which guarantees that the information that I provide will be treated in a confidential manner:  yes    no