Name:  E-mail:  Passport N°:  Phone Number:  Sex: Male   Female  Date of Birth:  Address:  Country:  My native language is:  I wish to study English for: Years   Months   weeks  I wish to register in: 1 Yr General English Student Visa Course 6 month General English (Full-Time) Cambridge Exam Preparation Courses  Other Course:  Date you wish to start Course:  Any medical conditions: Yes No  If yes, please state:  Do you require medical insurance? Yes No  Person to contact in case of an emergency:  The person speaks English: Yes No  Do you require accommodation? Yes No  If yes, please state: Host FamilyStudio Apartment Hotel  How long do you require accommodation for?  Please state date of arrival:  Do you require airport pick up on arrival? Yes No I agree with the terms and conditions See the English Language Academy Refund Policy

Please Note:
            All Course Fees must be paid in full with this registration.
            Valid Photo ID (Passport, Driver’s License) must also be presented.

Bank A/C Details:
            Bank of Ireland, College Green, Dublin 2.
            IBAN Code: IE77 BOFI 90001787 5515 92 BIC/ SWIFT Code BOFIIE2D
            Account Name: English Language Academy (ELA)

Please complete this form and return with full fees to Director of Studies, English Language Academy, (ELA), 21, Fairview, Dublin, Ireland or email it to info@elaireland.com along with proof of payment.