Title

First Name

Last Name:

Gender:

Male Female (required)

Date of Birth:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December ex.( 1999) (required)

Place of Birth:

Address

Address 2

City

Province / State

Country

Postal Code / Zip

Telephone

Fax

E-mail

Nationality

First Language

SIN/Passport#

1. ---Please Choose--- ESL TOEFL® TOEIC® Business English -------------------
2. ---Please Choose--- ESL TOEFL® TOEIC® Business English -------------------

3. ---Please Choose--- ESL TOEFL® TOEIC® Business English -------------------
4. ---Please Choose--- ESL TOEFL® TOEIC® Business English ESL + IT -------------------

Payment Method >>> Bank Transfer Credit Card Money Order Cash Debit Card ---select---- other:

Please select the schedule
of your choice:

Additional Schedule Comments

Education Completed

School Name

Program

English Level

What is your English level? Click here for level descriptors.

Most Recent Test

Do you require homestay?

yes no
If yes please fill in the following information

Start Date:

End Date: (If known):

Name of Agent: (if known)

Do you smoke

yes no

Do you like children

yes no
If yes what age range?

Do you have any alergies

yes no
If yes please specify

Do you want pets in your homestay

yes no
If yes please specify

Do you have any dietary restrictions?

yes no
If yes please specify

Other important homestay requirements

How did you hear about the
Victoria Internation Academy

If a Friend or Other, please explain

Additional Comments

All information on this form will be kept confidential and used for registration purposes only.

Student Registration
New Faxable Form!

Fill up the form online - save it.
(You may print it for your personal records.) Fax us back your Registration Form!
1-250-414-0103