WISMA BAHASA
REGISTRATION FORM - CLASS IN JAKARTA
 
A. PERSONAL DETAILS
Name : Male Female (required )
Place & date of birth (dd/mm/yyy) : (required field)
Permanent address :
Nationality : (required field)
Passport # :
Address in Jakarta :
Phone # (office/home/HP): (required field)
Email address : (required field)
Last education :
Company/Organization/University :
Occupation :
Language spoken :
Address for class :
   
B. LANGUAGE PROGRAMS  
Language(s) to register :
Indonesian
Current proficiency of the language :
None Basic/Survival Intermediate Advanced
  Please explain:
 

Emphasis :
Speaking Reading Listening Writing
Special requests related to your interests :
Expected result upon the completion of the training:
Course date (dd/mm/yyyy) :
to
  Prefered days :
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
  Prefered hours :
Session 1 (08.00 - 09.45) Session 4 (15.15 - 17.00)
Session 2 (10.15 - 12.00) Session 5 (17.15 - 19.00)
Session 3 (13.00 - 14.45)  
   
C. METHODS OF PAYMENT  
  Telegraphic transfer to:

Gregorius Haryana / Wisma Bahasa
A/C. 003 - 043 - 4931
Swift Code: BNINIDJAYGY
PT. Bank Negara Indonesia
Cab. Jl. Adisucipto no. 37, Yogyakarta, Indonesia
   
D. CANCELLATION AND REFUND  
Any cancellation must be made one day in advance. In an emergency situation (sick, accident), cancellation could be made with 1-hour notice in advance. Cancellation made less than 1 hour in advance or without any notice will be charged 50%.
   
How did you know Wisma Bahasa?
Internet  
Friends(s)  
Brochure  
Ex-student  
Organization, Company, School  
Others:  
(required field)  
   
Note :