LEARN SPANISH IN COSTA RICA AT INSTITUTO DE LENGUAS "We teach it, you learn it, together we live it" Phone: (506) 289-4396 Fax: (506) 228-1687 E-mail: ilerinst@sol.racsa.co.cr APPLICATION FORM Name Address City State Zip (Postal Code) Country Home Phone Work Phone Fax Number Email Birthdate Sex Male Female Marital Status Passport Job Emergency Contact Phone Number Spanish Level Beginner Intermediate Advanced Start Date End Date Option Number Weeks Time How did you hear about ILERI? FAMILY INFORMATION: Start Date End Date Prefer a family with children Yes No Need a special diet Yes No Smoker Yes No Other problems? Please specify: FLIGHT INFORMATION: Arrival Date Arrival time Airline Flight NOTE: PLEASE NOTIFY ILERI AT LEAST ONE DAY IN ADVANCE.