Registration Form

Student Agent

Marked Fields are required

For Agent
Student
Agency Name
Agent Name

Student Information
Title	Mr. Ms.
First Name
Middle Name
Family Name
Date of Birth
Citizenship
Mother Tongue
Home Phone
Mobile Phone
Email
Emergency Contact name
Emergency Phone number
Home Address	Line 1 :
	Line 2 (optional) :
	City / Town :
	State / Province / Region :
	Country :
	Postal Code :
Canadian Address	Line 1 :
	City / Town :
	State / Province / Region :
	Country :
	Postal Code :
Study Programs Primery Method of program Delivery : Inclass
Choose your program(s)	Online Classes Online Classes General ESL Program Intensive ESL (30 Lessons/Week) Practical English for Speaking (20 Lessons/Week) Semi-Intensive ESL (20 Lessons/Week) Pathway Program University Pathway (20 Lessons/Week) Test Preparation IELTS Preparation (20,10,4/Lessons/Week) TOEIC Preparation (20,10,4/Lessons/Week) Other ESL Program Diploma of Business Communication (20 Lessons/Week) - 8weeks Certificate of Business Communication (20 Lessons/Week) - 4weeks Diploma of Bilingual Language Skills (24 Lessons/Week) - 8weeks - (JP & EN)only Certificate of Bilingual Language Skills (24 Lessons/Week) - 4weeks - (JP & EN)only Work Experience Program (20-40hrs/Week) 4-12 weeks Night School ESL Full-Time (20 Lessons/Week) Part-Time (10 Lessons/Week) Package Program Bridge Program(Customized) Flexible Package Program Promotion Package-Intensive ESL (30 Lessons/Week)
Start Date of Study
Length of Study (weeks)
English Level
Type of Visa
Entry Date of Visa
Expire Date of Visa
Visa Number
Accommodation (Homestay)
Do you need homestay?	Yes No
Check In Date of Homestay
Check Out Date of Homestay
Length of Homestay (weeks / Nights)	/
Meal option	Private room with 2 meals Private room with 3 meals
Do you have any allergies?	Yes No
Accommodation (Residence)
Do you need residence?	Yes No
Check In Date of Residence
Check Out Date of Residence
Length of Residence (weeks / Nights)	/
Medical Information
Do you have Medical Insurance?	Yes No
If no, do you want to buy Medical Insurance from CanPacific?	Yes No
Start Date of Medical Insurance
Length of Medical Insurance (weeks / Days)	/
Airport Arrival Information (Optional)
Do you need airport pick-up?	Yes No
Arrival Date
Arrival Time
Airline
Flight Number
Do you need airport drop-off?	Yes No
custodianship letter Nedded	Yes No
Payment Information
When we receive your Registration form, we will send you a confirmation of your registration within 7 days. We will also dedicate you a detailed invoice, showing the fees for the programs you have selected. Please indicate how you would like to make your payment.
I will pay by	Credit Card in Cash (In Person only) Travelers Cheque Money Order / Bank Draft Bank Wire Transfer
Indicate when the payment will be sent to CanPacific
Comments

I confirm that I have read and I accept the terms and the conditions of the enrollment and school policy and refund policy with CanPacific College of Business & English as indicated on the website.

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