Family Name
Given Name
Date of Birth

DD/MM/YY Male Female

Address in Home Country

City
Country

Address in Australia (if known)

City

Home Phone
Work Phone
Fax
Email Address

Country of Birth
Nationality
Occupation
Passport
Type Of Visa
How did you hear about ICQA?
Indicate your level of language ability

StudentWorking HolidayTourist

Beginner Elementary Pre Intermediate
Intermediate Upper Intermediate Advanced

Highest Level of Education Completed
University
College
High School
Have you taken any other English Language Courses?
Yes No

If Yes -

Where
When
Type of Course
Length of Course

Have you completed any English Language Tests?Yes No

If Yes, which ones?
What was your score?

What do you wish to enroll in?

General English Course(20 hours per week) (Day)
General English Course(20 hours per week) (Night: 5:00PM to 9:15PM)
General English Intensive (25 hours per week)
Examination Preparation Course IELTS (20 hours per week)(Day)
Examination Preparation Course IELTS (20 hours per week)(Night: 5:00 to 9:15PM)
Examination Preparation Course IELTS (25 hours per week)
Buisiness English with TOEIC Preparation(20 hours per week)
Buisiness English with TOEIC Preparation(25 hours per week)
Others

Starting Date
Finishing Date
Total weeks of study:

Day: Month: Year:
Day: Month: Year:
weeks

Home Stay Share House Hotel Not Required

In Date
Out Date

Do you have any allergies? Yes No
If Yes, details

Do you wish to use our Transfer Service upon arrival? Yes No
If yes, please complete the following information:

Arrival Date:

(DD/MM/YY)

Arrival Time:

(HH/MM)

Arrival Airport:

Airline:

Flight Number:

3 months 6 months
9 months 12 months

Enrolment Fee
Course tuition / Fee
Airport Transfer
Teaching Materials Fee

Not Required One way $88.00 Return $176.00

Accommodation Research Fee
Accommodation Fee
Overseas Student Health Cover
Other Fees

Total (in $AU)

I Agree  I Disagree