Anexo3_ Enrolment Form

ENROLMENT FORM 1) Personal Information:  First Name:

Family Name:

Date of Birth:

Nationality:

Profession / Studies: Mother tongue:

Other languages known:

Home address: E-Mail: E-Mail used for the registration on the platform (compulsory):

2) Course Languages for which you wish to enrol in the ELS Platform:      Activities you are committed to carry out • • Existing knowledge of the languages indicated above (according to the Common European Framework of Reference) http://www.coe.int/T/DG4/Portfolio/?M=/main_pages/levels.html

Language chosen: ………………………..   

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Language chosen: ………………………..   

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Please explain why you need to learn the languages indicated above

Place and Date

Signature:

Please send the Enrolment Form to Pixel : e-mail: [email protected] or Fax. +39-055-4628873 or to Pixel – Via Luigi Lanzi 12 – 50134 Firenze (Italy)