Registration Form for Classes and Seminars in Connecticut

Please fill in the following information and send it to us via Internet to reserve a place in a course. You will receive an email with payment information. Registration is not complete until payment is received.

You may also register via Fax or mail. Click here to download this form in RTF format. Fill out the form and Fax it to 860-691-0358 or mail it to Impact-e English Training / 169 Upper Pattagansett Road / East Lyme, CT 06333.

Participant Information

Please enter the following information:

First Name:   Last Name:
Address:   City:
State:   Zip Code :
Email Address:   Telephone Number:
Company   Department:

What training would you like to register for?

(Please list name, location and date. E.g. Intensive Business English in New London on March 7th & 8th)

Billing contact:

(If your company or another person will pay for the training, please enter the contact person's name, address, telephone number, etc.)

Please answer the following questions with complete sentences:

Did you have English in school? ( If yes, for how long and when.)

Have you had any English lessons since then? (If yes, for how long, when and where)

What are your specific goals for the English training?

How would you describe your English level?

How did you hear about this course?

Is there anything else we should know about you?

 

Enter your email address (required for "Send" action):