ENROLLMENT FORM 2008

1. Personal details

Family Name

First Name

Sex

Date of Birth

Country of Birth

Town of Birth

Nationality

Address

Post code		Town		Country
Contact tel.		Fax.		E-mail

Who to contact in case of emergency during yourstay 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

2. Visa Related Information

Passport number

Date of issue

Expiration date

Occupation

Address of work/study place

What city is the Russian Consulate located (where will you apply for the Russian visa)?

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)

3. Accommodation

Homestay

Guest house/hostel/hotel

Organized independently

Please write the address of staying in St. Petersburg (important for visa support)

4. Airport transfer

Do you require airport transfer on arrival?
Yes		No

Arrival details:

Date of arrival

Flight number

Arrival time

Do you require airport transfer on departure?
Yes		No

Departure details:

Date of departure

Flight number

5. Cource Details

Type	Lessons per week	Start date (dd/mm/yy)	Number of week
Standart Course	20
Intensive Course	30
Academic/Long-Stay	20
Business Russian Combinational Individual	30 10 15 20 35
Exam Preparatory Block	10 15 20
One-to-one*	10 15 20 30
Evening Course	Mon/Wen Tue/Thu
In-company Individual lessons Mini group lessons	10 15 20
Work and study	20

*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 learn about Derzhavin Institute?