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> Please complete the Reservation form below (the fields marked with * must be completed) then click "Submit" to book your stay Last Name : * First Name : * Date of Birth : (dd/mm/yyyy)* Gender : M F Address : *   Zip code : * City : * Country : * Telephone 1 : Telephone 2 : E.mail : * Level of french : Choose a level Complete Beginner Beginner Elementary Intermediate Advanced I don't know yet * (see "French Levels" on alfmed.com for more details) Choice of Program : Choose a program Basic Program Business Combinated Program Barcelona Combinated Program Golf Combinated Program Sailing Combinated Program Equitation Combinated Program A la carte * (see "Various Programs" on alfmed.com for more details) Choice of stay : Choose a stay 1 month (Intensive Program) 2 months (Intensive Program) 4 months (Academic Semester) 8 months (Academic Year) Other (Precise on bottom) * Starting Month : Choose a month January February March April May June July August September October November December * Year : Choose a year 2005 2006 2007 2008 2009 * You will come :* Alone    with a group of people Choice of Lodging : Choose a lodging With housemates in a two bedroom With housemates in a single bedroom In a individual apartment With a host family I have already a lodging * (see "Lodging Prices" on alfmed.com for more details) Please indicate any information you may consider important for your lodging To book your stay at the Academy, you must pay the Registration Fee of 150 euros (non-refundable) which includes the Administrative formalities. This amount will be deducted from the total price of your stay. Method of Payment :* proceed to payment for the Registration Fee of 150 euros to reserve your stay Bank transfer to ALFMED 21 bis Ave du Général de Gaulle - 66000 PERPIGNAN - France Bank : Société Marseillaise de Crédit 1, place Bardou Job - 66000 Perpignan - FRANCE Tél. : +33 468 257 272 – Fax : +33 468 357 299 Bank Transfer : IBAN : FR61 3007 7017 0000 0025 8272 Q49 BIC : SMCTFR2AXXX Credit Card : If you choose this method, Alfmed will contact you by phone for the transaction (please indicate a valid telephone number on the "Personal Détails" part of this form) You will receive by email the receipt of your payment and confirmation of conditions The balance of fees must be paid 2 weeks before arrival. The Registation Fee is non-refundable. Please see registration conditions and cancellation policy on the website : "Various programs and agreements" Once the final receipt will be issued, you will have to fill-in your arrival details. So we will take care of your welcome ! If you need to make any additional commentary I accept the conditions of Registration at Académie de Langues France MEDitérranée According to the 01/16/1978 law, you can have access and modify personal information. ALFMED respects the privacy of the users of this website. You may change or delete your details at any time, contact us.

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