Please print out complete, and send to the following address:

HALLER
Bahnhofstr. 70 
D-66111 Saarbrücken 
Tel. ++49-681-36981
FAX. ++49-681-3906656  

Course application: I hereby apply for a place on the course indicated below:

1.	Personal data:
Name: Mr. Mrs. Ms.
Address:
Forename:
Date of birth:
Private address:
Street:
Town, Post Code (Zip code) :
Telephone:
(Fax, E-mail)



2.	Employed by:
	Position/Responsibilities:
	Telephone:

3.	Course required:
		( ) German
		( ) French
		( ) English
		( ) Other 
		( ) Group
		( ) One-to-one tuition

		Date: from 			to		number of weeks

4.	Background knowledge:	( )	School	years

	Explanations:

5.	Based on the current pricing schedule the course fee is: €
	
	Supplementary requirements:

6.	The application becomes legally effective on receipt by the Institute and written acknowledgement.  With application from 8 weeks prior to the start of the seminar 10 % of the course fee becomes due, from 4 weeks 20 %, from 2 weeks 50 %.

Cancellation 10 days prior to the start of course, or in the event of non-attendance, 50 % of the course fee is due, unless a replacement participant has been supplied. 

Applications close 10 days before course/seminar commences.
 
7.	Accommodation costs:

	Costs for accommodation in a hotel or a guest family should be settled direct with the hotel or family;  reservations or preferred choice of  guest family as per data below is made via the Haller-Secretariat.


8.	Accommodation:
	Would you like to stay with a family?			( ) yes	( ) no
	Do you smoke?                             ( ) yes	( ) no
	Will you be coming in your own car?       ( ) yes	( ) no
	Shall we book a hired car for you?        ( ) yes	( ) no
	Car category (class):
	Would you prefer to stay in a hotel?     ( ) yes	( ) no
	If so, which hotel would you like?
	Category A	( )
	Category B	( )
	Category C	( )
	Date of first night:
	Date of last night:
	
	Other:

Place/Date:				Signature:




Self-assessment of knowledge of foreign language:

Please tick the most appropriate:

1 ( )	I have no knowledge of the foreign language; I know only a few words and phrases.

2. ( )	I have some knowledge of the foreign language, just enough in order to find my way around in every-day situations.  I cannot hold a fluent conversation.

3 ( )	My knowledge of languages is adequate to hold a simple conversation and to read easy text, but I still make many mistakes in pronunciation, choice of words, using the right expression and in grammar, which means communication is not smooth.

4 ( )	I use the language so that everyone can understand me in every-day situations, but I quite often mistakes in the choice of words, flow of speech and sentence construction. However, communication is usually successful.

5 ( )	I can cope with difficult language situations and I read demanding text, but occasionally I make mistakes in linguistic accuracy, choice of words and grammar. Telephoning in the foreign language is no problem for me either.

6 ( )	I speak the foreign language almost like my native language and I can negotiate in the foreign language.  Only in technical conversations, demanding film dialogues, shows etc. do I have occasionally problems perceiving what is being said.