Istituto Linguistico Mediterraneo

Print the form with the Browser, fill it in, either typewritten, or in legible handwriting, and send it by post to:
Istituto Linguistico Mediterraneo, Via C. Battisti N° 3 - C.P. 209, I-56100 Pisa (Italia) or via Fax at ++39 050 48157

Name:

Mrs.

Miss

Mr.

Surname:

Date of birth:

Address (Str.):

Postal code:

City:

Country:

Tel:

Fax:

E-Mail:

Present knowledge of Italian language:
none	little	medium	good

I would like to book the following course. (Type of course)

from	to	N° weeks

**Accommodation**
Please do not reserve any accommodation

I would like to reserve accommodation (please indicate two possibilities):
Family	bed and breakfast
	half board
Room in apartment, with common kitchen and bathroom
Apartment
Pension
Hotel

If possible, I would like a single room. (if single rooms are not available, the school will automatically reserve a bed in a double room)

Payment terms
I have paid an advance of 30% of the price of the course by:

International money order addressed to: Istituto Linguistico Mediterraneo Via C. Battisti n° 3 - C.P. 209 I-56100 Pisa / Italia	Payment into Current Bank Account:

I declare that I have read the school regulations and accept them .

Date:

...............................................

Signature:

...............................................