registration form...registration form a student information c program preference b agent d device...

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REGISTRATION FORM A Student Information C Program Preference B Agent D Device City: Country: Agent Email: Weeks City: Start Date: Adult Intensive Program Young Adult Intensive Program (ages 14-18) If you are unsure what time your lessons start in your time zone, please visit ilackiss.com Emergency Contact: Province: Postal Code: Last Name:姓 First Name:名 Gender:性別 Date of Birth: Nationality: Primary Language: Passport #: Yes Yes Yes Slot 1 Slot 3 Slot 2 Slot 4 General English Business English University Pathway IELTS Preparation Cambridge Preparation No No No E-mail: Country: F X Address: Desktop Laptop Tablet Smartphone Other (specify below) M 生年月日現住所国都道府県市・区郵便番号国籍職業緊急連絡先氏名 Emergency Contact Phone: 緊急連絡先電話番号 Are you currently in Canada? 現在カナダに滞在中ですか？ Are you planning on attending a University or College in Canada? 母国語パスポート番号コース修了後は、カナダの大学やカレッジに進学予定ですか？入力不要 Have you been in contact with an agent? Agency: Contact Agent: Select a program: ご希望のプログラムに印をつけてください。 Select a course: ご希望のコースに印をつけてください。 Select a time slot: ご希望の時間帯に印をつけて下さい。 21：30～ 06：30～ 01：00～ 10：00～ Number of Weeks:お申込期間ご希望開始日どのタイプのデバイスをご利用されますか？印を入れてください。 What device will you デスクトップPC ノートPC タブレットスマートフォンその他 access classes on? Device model: その詳細をご記入ください。 Ryugaku Journal Ryugaku Journal Tokyo Japan [email protected]

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Page 1: REGISTRATION FORM...REGISTRATION FORM A Student Information C Program Preference B Agent D Device City: Country: Agent Email: Weeks City: Start Date: Adult Intensive Program Young

REGISTRATION FORM

A

Stu

den

t In

form

atio

nC

P

rog

ram

Pre

fere

nce

B

Ag

ent

D

Dev

ice

City: Country:

Agent Email:

Weeks

City:

Start Date:

Adult Intensive Program

Young Adult Intensive Program(ages 14-18)

If you are unsure what time your lessons start in your time zone, please visit ilackiss.com

Emergency Contact:

Province: Postal Code:

Last Name:姓

First Name:名

Gender:性別

Date of Birth:

Nationality:

Primary

Language:

Passport #:

Yes

Yes

Yes

Slot 1 Slot 3

Slot 2 Slot 4

General English

Business English

University Pathway

IELTS Preparation

Cambridge Preparation

No

No

No

E-mail:

Country:

F X Address:

Desktop Laptop Tablet Smartphone Other (specify below)

M

生年月日

現住所

国

都道府県

市・区

郵便番号

国籍

職業

緊急連絡先氏名

Emergency Contact Phone:緊急連絡先電話番号

Are you currently in Canada?現在カナダに滞在中ですか？

Are you planning on attending a University or College in Canada?母国語

パスポート番号コース修了後は、カナダの大学やカレッジに進学予定ですか？

入力不要

Have you been in contact with an agent?

Agency:

Contact Agent:

Select a program:ご希望のプログラムに印をつけてください。

Select a course:ご希望のコースに印をつけてください。

Select a time slot:ご希望の時間帯に印をつけて下さい。

21：30～ 06：30～

01：00～ 10：00～

Number of Weeks:お申込期間ご希望開始日

どのタイプのデバイスをご利用されますか？印を入れてください。 What device will you

デスクトップPC ノートPC タブレットスマートフォンその他access classes on?

Device model:その詳細をご記入ください。

Ryugaku Journal

Ryugaku Journal

Tokyo Japan

[email protected]

http://www.ilackiss.com

Page 2: REGISTRATION FORM...REGISTRATION FORM A Student Information C Program Preference B Agent D Device City: Country: Agent Email: Weeks City: Start Date: Adult Intensive Program Young

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