REGISTRATION FOR CENTRO PUCCINI COURSES

To obtain more information about Scuola Leonardo da Vinci, please complete this form and click on the "Request Information" button at the bottom of this page. Please include your telephone numbers, e-mail or fax number on the form, in order for us to contact you more easily if we need further information.

Thank you for your interest in the Leonardo da Vinci schools!

PERSONAL DETAILS

Mr. Mrs. Ms.

First Name:
Surname:

Date of Birth:
Day: Month: Year:

Nationality:
Mother Tongue:

Profession/Studies:

Home Address (Street):

City:
Zip/Post Code:
Country:
Telephone (Home):
Telephone (Work):
Facsimile:

E-mail Address:

How did you hear about Centro Giacomo Puccinii?

If you found us on the Internet please specify where:

If 'others' or 'via an agency' please specify:

Why did you choose Centro Giacomo Puccini?


COURSES:

Course 1: I wish to enroll in the following course:

If you choosed "professional courses", please specify from the list below

Starting Date: Day: Month: Year:
Number of weeks:  

Course 2: I wish to enroll in the following course:

If you choosed "professional courses, please specify from the list below

Starting Date: Day: Month: Year:
Number of weeks:  

MY KNOWLEDGE OF ITALIAN:

Have you already studied Italian?

No Yes

If 'Yes' please complete the following:

University/School:

Street:

Zip/Post Code:
City:

Name of your Teacher:

Self evaluation:   


MY ACCOMMODATION:

I wish the school to provide my accomodation:

No Yes

If 'Yes' please complete the following:

Apartment  Room type:  
  Single Room  
  Double Room  
Family Room type:  
  Single Room breakfast half-board
  Double Room  
Hotel** Room type: breakfast half-board
  Single Room  
  Double Room  

Others, please give details

Do you smoke? No Yes
Do you have any allergies? No Yes

if yes please give details

 

   

Do you need a special diet?

No Yes
if yes please give details  

Do you need a transfer? No Yes
If 'Yes' please give details:    Arrival date: day month year

Arrival time:
Arrival location:
Flight Number:
Train Number:

Special requests/observations:


PAYMENT:

Note that if you are registering more than 30 days before the beginning of the course, we require a deposit payment of 70 Euro. If you prefer, you can also pay the total course fees at once.

If you are registering less than 30 days before the beginning of the course, we require the payment for the total course fees.

I have already paid the amount of EURO by means of:

Cheque internacional
Orden de Pago Postal
Bank transfer

To: centro culturale g. puccini srl
Bank: intesa sanpaolo (P.zza M.D’azaglio, 44 IT-55049 Viareggio (LU), tel +39 0584 325711)
sban: IT71 I030 6924 8000 7810 9260 124
swift: BCITITMM


My registration implies the acceptance of the "Terms and Conditions of participation" as mentioned in our Web site or brochure.

Consent in accordance with Art. 23 of D. Lgs. 196/2003. The person concerned, having received the information furnished by the data processing owner in accordance with Article 13 of D.Lgs. 196/2003, hereby consents to the processing of his/her personal data for the purposes indicated in the aforesaid informative note. He/she also consents to the communication of his/her personal data for the purposes and to the subjects indicated in the informative note.

Place and date: