On-line Application Form
Please fill in the questions below.  If you need more information, please fax us at 1-604-688-7242, or e-mail van@pli.ca

Personal Information

Title: 
Family name: 
Given name: 
Birthdate:  , 19
Nationality: 
Native language:
Contact Information

Street: 
City: 
Country: 
Postal Code: 
Phone number: 
Fax number: 
E-mail address: 
Study

I would like to study in:
I would like to start , 20
 and finish ,  20
I would like to register for hours per week.
My English level is
I would like to study
Communication Program
Business English
Cambridge Exam Program   

TOEFL Exam Program
TOEIC Exam Program
English Internship Program
Have you ever written any previous ESL exams?
Yes
No
Year:   Score:   Exam:
Homestay

I will need a homestay family
Yes
No
I prefer
Full board
Premium Full board
Half board
Premium Half board
 Premium Homestays guarantee a private bathroom
I would like to start homestay
, 20
 and plan to stay month(s).
I will need airport pick-up
Yes
No
I would like apartment options (if yes, we will send details)
Yes
No
Many families have pets.
Can you live with a cat?
Yes
No
A dog?
Yes
No
I prefer families:
with children    Ages?
adult home
Please list any allergies, special medications, or health problems:
Are you a smoker?
Yes
No
Many families are non-smoking and as a result have some restrictions.
Interests & Hobbies:
Comments for Host Family:
Emergency Contact

Name: 
Relationship: 
Phone: 
Fax: 
Contacting You

How should we contact you?
Telephone
Fax
Mail
E-mail
How did you find out about us?

Enter your Questions or Comments:

Note: you will not be put on a mailing list; all information sent to us will only be used for the purpose of providing you with homestay and accommodation information.  You can send your fees by international money order or send a wire directly to our account.  Please check our Refund Policy before registering.


THANK YOU!