| PERSONAL DETAILS |
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Mrs.
Ms.
Mr. |
| Surname*: |
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| Firstname*: |
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| Date of Birth*: |
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YYYYMMDD |
| Nationality |
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| Occupation* |
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| Address* |
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| City* |
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| Post Code* |
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| Country* |
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| Email* |
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| Tel*: |
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| Mobile: |
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| Fax: |
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| Number of Students*: |
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Please indicate the number of people
you are booking for |
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| Company: |
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| COURSE |
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| Course* |
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How did you
hear about us? |
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| ACCOMMODATION |
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| Travel infos |
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NB Group packages already include accommodation, please
skip the following section. Please choose ONE of the
following: |
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| Health: |
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Allergies or dietary needs? |
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If you chose to stay with a host family, to help us select a family best suited for you, we would like to know a
little more about you (likes and
dislikes, interests, personality, special needs etc.) |
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| PAYMENT |
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We use Paypal secure e-mail payment (for more information about this service and its security, please have a look at www.paypal.com). This payment service is easy to use and offers excellent security.
Upon reception of your booking form, we will email you a demand of payment through the Paypal website. This demand will include a detailed bill of your tuition and accomodation fees. You can follow the instructions in this email to make your online payment on Paypal. |
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| SUBMIT BOOKING |
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I hereby confirm that
I have read the Coucouchine Terms & Conditions. |
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