Summer Credits - Online Application Form

Home
Our Courses
Program Costs
Accommodations
Info. Sessions
News/Itinerary
Memory Lane
Apply Now
About Us
Contact Us

The Irish Experience Application Form

Simply fill in the form below on-line to book a place or print the application form and send it with cheque for the deposit of $1250.00, payable to: Kemptville Travel Ltd to:

The Irish Experience,
88 Eglinton Ave West,
Toronto, ON., M4R 1A2.

PDF Application Form

1. Program Information(Course selection)

First Choice:

Second Choice:

2. Applicant Information

First and Middle Name:
(Exactly as on passport)

Last Name:
(Exactly as on passport)

Mailing Address:

City and Province/State:

Postal/Zip Code:

Email address:

Residence Phone:

Country of Citizenship:

Gender:

MaleFemale

Date of Birth:

Place of Birth:

Passport Number(if available):

Issuing Country:

Expiry Date:

3. Parent/Guardian Information

First Name:

Last Name:

Relationship:

MotherFatherOther

If other, please specify:

Business Phone:

Email:

4. School Information

School Presently Attended:

Address:

Name of School Contact:

Phone:

Most recently completed English Course (by June 30 2012):

Do you have an Individual Education Plan (IEP)?

YesNo

5. Additional Information

How did you hear about this course:

Special requests (e.g.sharing with another student) or medical information:

6. Payment Information

Instructions: A deposit of $1,250 must accompany this application.

Please debit my:

VisaMaster CardAmerican Express

In the amount of:

$ CAD

Card Number:

Name on card:

Expiry Date:

Year:

I hereby authorize Kemptville Travel Ltd. to debit my credit card for the deposit as indicated above. I have read and understood the terms and conditions and I also agree to not dispute or charge-back these amounts. Kemptville Travel Ltd. is a registered travel agency under the Travel Industry Act (TICO Registation # 2347696), and funds are fully protected under the TICO Compensation Fund.

Apply Now!

The Irish Experience

88 Eglinton Ave West,
Toronto, ON., M4R 1A2.

Tel.:(905) 804-9402
Toll-free 1 (877) 304-9402

For more information, please contact:
Garry O'Sullivan - Program Director

Simply fill in the form below on-line to book a place or print the application form and send it with cheque for the deposit of $1250.00, payable to: Kemptville Travel Ltd to:

The Irish Experience

Follow us:

Our Blog for 2011 Group