Application form (can be printed and sent by fax)
Name (in full)   .......................................................................
Born in   .................................................. on ........................
Nationality   .................................................... pass. n°  ........................

Address    ..............................................................................................

..............................................................................................................

Town   ..............................................     Country  ...................................
Tel.   ............................................   Fax   ..............................................
Sex   ..........................   E.mail   ............................................................    

Knowledge of italian       nil ......    little ...... medium...... good ......

I want to take part in the language course for the month of .......................


Course + excursion:
( )
4 weeks 496 Euro    ( ) 3 weeks 450 Euro    ( ) 2 weeks 350 Euro

( ) Double Room in apartment: 7,5 Euro per night
( ) Single Room in apartment: 13 Euro per night
( ) Single Flat: 20 Euro per night (kitchen, bath, balcony, bedroom 2 pax)

I enclosed the deposit for accommodation:

*( ) Proof of a postal order for 196 Euro made payable to "Comitato D. Alighieri" 
Via E. Mattei, 69 - cap 62022 Castelraimondo (Macerata) - Italy.

*( ) Traveller's cheque non trasferable for 196 Euro made payable to "Comitato D. Alighieri".

*( ) Bank trasfer of 196 Euro:
Bank: Banca Popolare di Ancona
Branch: Castelraimondo
Name: Comitato Dante Alighieri
Account number: 1317/77 ABI 5308 CAB 68840

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Card no.  _ _ _ _    _ _ _ _    _ _ _ _     _ _ _ _

EXPIRY date   _ _    _ _

Signature & Date    ..............................................................

Società Dante Alighieri - Comitato di Camerino
Corsi di Lingua e Cultura Italiana per stranieri

Via E. Mattei, 69 - 62022 Castelraimondo (MC) - ITALIA
Tel. +39 0737 642611 - Fax +39 0737 643161
Email: centroalighieri@scuoladantealighieri.org