Family Name
Country of Birth
First Name
City of Birth
Sex
Nationality
Date of Birth
Address
Zip code
City
Country
Contact tel.
Fax.
E-mail
Who to contact in case of emergency during your stay in Russia
Possible arrival (dd/mm/yy)
Possible departure (dd/mm/yy)
Do you need the visa support?
Yes*
No
*if yes, fill in item 2, please
Passport number
Date of issue
Expiration date
Occupation/job
Address and telephone number of your workplace or Name of the educational establishment
Where will you apply for the Russian visa(country, city)?
What cities in Russia are you planning to visit?
Please send the copy of your passport to the e-mail address info@derzhavin.com (important for getting Russian visa)
Homestay
Half-board
Breakfast
Single room
Shared room*
Standart Type
*Shared rooms are only available for two students booking together
Do you have any specific dietary requirement?
Yes
Details
Do you have any allergies?
Guest house/hostel/hotel
Guest house
Shared room
Date of arrival (dd/mm/yy)
Date of departure (dd/mm/yy)
Numbers of weeks/days
Hostel
Choose from the list http://www.derzhavin.com/en/pages/263/
Name of hostel
Hotel
Choose from the list http://www.derzhavin.com/en/pages/265/
Name of hotel
Organized independently
Please write the address of staying in St. Petersburg (important for visa support)
Shared flat
Do you require airport transfer on arrival?
Arrival details:
Date of arrival
Flight number
Arrival time
Do you require airport transfer on departure?
Departure details:
Date of departure
Departure time
Type
Lessons per week
Start date (dd/mm/yy)
Number of week
Standart Course
20
Intensive Course
30
Academic/Long-Stay
Business Russian
Combinational
Individual
10
15
35
Exam Preparatory Block
One-to-one*
Evening Course
Mon/Wen
Tue/Thu
In-company
Individual lessons
Mini group lessons
Work and study
Other course type
*Special interests of study (only for One-to-one)
Native language
Other languages
How do you assess your level of Russian
Beginner
Elementary
Pre- Intermediate
Intermediate
Pre- Advanced
Advanced
Previous Russian languages courses - Please indicate year of study, place of study, course length and course intensity (hours per week):
How did you find Derzhavin Institute?
We work: Mon.-Fr. 09.30 - 22.00 Phone: +7 (812) 740 19 26 Our address: 118 Fontanka, Saint-Petersburg, Russia