Spanish Institute of Puebla - Registration Form

<BODY BGCOLOR=#5684B6 link="#5684B6" vlink="#5684B6" alink="#5684B6" LEFTMARGIN=0 TOPMARGIN=0 MARGINWIDTH=0 MARGINHEIGHT=0>  <div align="center"> <TABLE WIDTH=800 BORDER=0 CELLPADDING=0 CELLSPACING=0> <TR> <TD> <IMG SRC="Images/registrationmain_01.gif" WIDTH=800 HEIGHT=90 ALT=""></TD> </TR> <TR> <TD bgcolor="#FFFFFF"> <p> </p> <p align="justify"><font color="#5684B6" size="2" face="Tahoma"><strong>You are on your way to Speaking better Spanish... To reserve your space in our program just fill out the following registration form and submit it. To complete your registration we require a non-refundable $100.00 usd deposit. The deposit will be used as part of your course fees.</strong></font></p> <FORM METHOD=POST ACTION="https://secure.liber.lunarservers.com/~sipue0/correo.pl"> <input type=hidden name="recipient" value="sipuebla@yahoo.com"> <input type=hidden name="subject" value="Registration Form"> <input type=hidden name="redirect" value="https://secure.liber.lunarservers.com/~sipue0/response-registration.htm"> <A NAME="64"></A> </div> <TABLE BORDER=0> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Name: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Name" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Address: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Address-1" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Address: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Address-2" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>City: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="City" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>State: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="State" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Zip_Code: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Zip" TYPE="TEXT" VALUE="" Size=6> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Country:</strong> </font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Country" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Phone: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Phone" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>E-mail: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="E-mail" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"> </font></TD> </TR> <TR> <TD WIDTH=8% ALIGN=TOP><font size="2" face="Tahoma"> <strong>Sex:</strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Sex:" TYPE="RADIO" VALUE="Male"> Male <INPUT NAME="Sex:" TYPE="RADIO" VALUE="Female"> Female<BR> </font></TD> </TR> <font size="2" face="Tahoma"> </font> <font size="2" face="Tahoma"> </font> <TR> <TD ><font size="2" face="Tahoma"><strong>Marital Status:</strong></font></TD> <TD ><font size="2" face="Tahoma"> <SELECT NAME="Marital Status:" SIZE=1> <OPTION VALUE="Single">Single <OPTION VALUE="Married">Married <OPTION VALUE="Divorced">Divorced <OPTION VALUE="Widow/er">Widow/er </SELECT> </font> </TR> <font size="2" face="Tahoma"> </font> <TR> <TD ><font size="2" face="Tahoma"><strong>Age:</strong></font></TD> <TD ><font size="2" face="Tahoma"> <SELECT NAME="Age:" SIZE=1> <OPTION VALUE="18-25">18-25 <OPTION VALUE="26-35">26-35 <OPTION VALUE="36-45">36-45 <OPTION VALUE="46-55">46-55 <OPTION VALUE="56+">56+ <OPTION VALUE="16-18">16-18 </SELECT> </font> </TR> <font size="2" face="Tahoma"> </font> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Profession:</strong> </font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Profession" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong>Person to Contact in Case of Emergency:</strong><BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Name: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Contact Name" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>Phone: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Contact Phone" TYPE="TEXT" VALUE="" Size=20> <BR> </font></TD> </TR> <TR> <TD WIDTH=8%><font size="2" face="Tahoma"> <strong>E-mail: </strong></font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Contact E-mail" TYPE="TEXT" VALUE="" Size=30> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong>Starting Date of Program:</strong><BR> </font></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <SELECT NAME="Starting Date" SIZE=1> <OPTION VALUE="December 6th, 2004">December 6th, 2004 - No Spaces Available <OPTION VALUE="January 3rd, 2005">January 3rd, 2005 <OPTION VALUE="January 31st, 2005">January 31st, 2005 <OPTION VALUE="February 28th, 2005">February 28th, 2005 <OPTION VALUE="March 28th, 2005">March 28th, 2005 <OPTION VALUE="April 25th, 2005">April 25th, 2005 <OPTION VALUE="May 23rd, 2005">May 23rd, 2005 <OPTION VALUE="June 20th, 2005">June 20th, 2005 <OPTION VALUE="July 18th, 2005">July 18th, 2005 <OPTION VALUE="August 15th, 2005">August 15th, 2005 <OPTION VALUE="September 12th, 2005">September 12th, 2005 <OPTION VALUE="October 10th, 2005">October 10th, 2005 <OPTION VALUE="November 7th, 2005">November 7th, 2005 <OPTION VALUE="December 5th, 2005">December 5th, 2005 <OPTION VALUE="January 9th, 2006">January 9th, 2006 <OPTION VALUE="February 6th, 2006">February 6th, 2006 <OPTION VALUE="March 6th, 2006">March 6th, 2006 <OPTION VALUE="April 3rd, 2006">April 3rd, 2006 <OPTION VALUE="May 1st, 2006">May 1st, 2006 <OPTION VALUE="May 29th, 2006">May 29th, 2006 <OPTION VALUE="June 26th, 2006">June 26th, 2006 <OPTION VALUE="July 24th, 2006">July 24, 2006 <OPTION VALUE="August 21st, 2006">August 21st, 2006 <OPTION VALUE="September 18th, 2006">September 18th, 2006 <OPTION VALUE="October 16th, 2006">October 16th, 2006 <OPTION VALUE="November 13th, 2006">November 13th, 2006 <OPTION VALUE="December 11th, 2006">December 11th, 2006 </SELECT> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong>Number of weeks you plan to attend:</strong><BR> </font></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <SELECT NAME="No. of Weeks" SIZE=1> <OPTION VALUE="4 weeks">4 weeks <OPTION VALUE="8 weeks">8 weeks <OPTION VALUE="12 weeks">12 weeks <OPTION VALUE="16 weeks">16 weeks <OPTION VALUE="20 weeks">20 weeks <OPTION VALUE="24 weeks">24 weeks </SELECT> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong>If attending <A HREF="http://www.sipuebla.com/one-on-one.htm" target="_top">Individual Program</A> mark below:</strong><BR> </font></TD> </TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <input type="checkbox" name="Individual Program" unchecked value="YES"> Individual Program <input type="text" size="24" name="Start Date" value="Write start date here!"> No. of Weeks: <SELECT NAME="Ind. Weeks" SIZE=1> <OPTION VALUE="1 week">1 week <OPTION VALUE="2 weeks">2 weeks <OPTION VALUE="3 weeks">3 weeks <OPTION VALUE="4 weeks">4 weeks <OPTION VALUE="5 weeks">5 weeks <OPTION VALUE="Other">Other </SELECT> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><p><font size="2" face="Tahoma"><strong><font color="#000000">Spanish level you will like to start in ( <a href="http://www.sipuebla.com/placement_test.htm" target="_top">Take Placement Exam</a> optional ):</font></strong><BR> </font></p></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <SELECT NAME="Level" SIZE=1> <OPTION VALUE="Beginner">Beginner <OPTION VALUE="Beginner/Intermediate">Beginner/Intermediate <OPTION VALUE="Intermediate">Intermediate <OPTION VALUE="Advanced">Advanced <OPTION VALUE="Superior">Superior <OPTION VALUE="Native">Native <OPTION VALUE="Not Sure">Not Sure </SELECT> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong><font color="#000000">Knowledge of Spanish (25 words or less):</font></strong><BR> </font></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <TEXTAREA WRAP=OFF NAME="Spanish kwnowledge" ROWS=5 COLS=45> </TEXTAREA> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong><font color="#000000">Requests regarding Homestay:</font></strong><BR> </font></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <TEXTAREA WRAP=OFF NAME="Homestay requests" ROWS=4 COLS=45> </TEXTAREA> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong><font color="#000000">Deposit ($100 usd) will be paid by:</font></strong><BR> </font></TD> </TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Deposit by" TYPE="RADIO" VALUE="Check"> Check<BR> </font></TD> </TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <INPUT NAME="Deposit by" TYPE="RADIO" VALUE="Credit Card"> Credit Card  <SELECT NAME="Credit Card" SIZE=1> <OPTION VALUE="Visa">Visa <OPTION VALUE="MasterCard">MasterCard </SELECT> <BR> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma">                      Credit Card #:  <INPUT NAME="1st" VALUE="" SIZE="4" MAXLENGHT="4"> - <INPUT NAME="2nd" VALUE="" SIZE="4" MAXLENGHT="4"> - <INPUT NAME="3rd" VALUE="" SIZE="4" MAXLENGHT="4"> - <INPUT NAME="4th" VALUE="" SIZE="4" MAXLENGHT="4"> </font> </TR> <font size="2" face="Tahoma"> </font> <TR> <TD COLSPAN=2><font size="2" face="Tahoma">                      Expiration Date:  <SELECT NAME="expired month"> <OPTION VALUE="January">January <OPTION VALUE="February">February <OPTION VALUE="March">March <OPTION VALUE="April">April <OPTION VALUE="May">May <OPTION VALUE="June">June <OPTION VALUE="July">July <OPTION VALUE="August">August <OPTION VALUE="September">September <OPTION VALUE="October">October <OPTION VALUE="November">November <OPTION VALUE="December">December </SELECT> <SELECT name="expire year"> <OPTION VALUE="2004">2004 <OPTION VALUE="2005">2005 <OPTION VALUE="2006">2006 <OPTION VALUE="2007">2007 <OPTION VALUE="2008">2008 <OPTION VALUE="2009">2009 <OPTION VALUE="2010">2010 </SELECT> </font> </TR> <font size="2" face="Tahoma"> </font> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"> </font></TD> </TR> <TR> <TD COLSPAN=2><font size="2" face="Tahoma"><strong><font color="#000000">Please use this space for any comments:</font></strong><BR> </font></TD> </TR> <TR> <TD><font size="2" face="Tahoma"> </font></TD> <TD><font size="2" face="Tahoma"> <TEXTAREA WRAP=OFF NAME="Comments" ROWS=5 COLS=45> </TEXTAREA> <br> <br> </font> </TR> <font size="2" face="Tahoma"> </font> <TR><TD COLSPAN=2>How did you find out about the Spanish Institute of Puebla? (please specify if possible)<br></TD></TR> <TD></TD><TD><input type="checkbox" name="Formerst" unchecked value="ON"> Former student <input type="text" size="41" name="Formerna" value="Write student name here!"> <br></TD></TR> <TD></TD><TD><input type="checkbox" name="Employer" unchecked value="ON"> Employer <input type="text" size="47" name="EmpName_" value="Write company name!"> <br></TD></TR> <TD></TD><TD><input type="checkbox" name="Ad______" unchecked value="ON"> Ad in newspaper/magazine <input type="text" size="30" name="Adname__" value="Write name of magazine here!"> <br></TD></TR> <TD></TD><TD><input type="checkbox" name="Universi" unchecked value="ON"> My University/college <input type="text" size="35" name="UniName_" value="Write name of university here!"> <br></TD></TR> <TD></TD><TD><input type="checkbox" name="Search__" unchecked value="ON"> I used a Web search service: <input type="text" size="28" name="WebSearc" value="Write search engine here!"> <br></TD></TR> <TD></TD><TD><input type="checkbox" name="Other___" unchecked value="ON"> Other source: <input type="text" size="43" name="Othernam"> </font> <br><P> </TD></TR> <TR><TD COLSPAN=2><INPUT TYPE="SUBMIT" VALUE="Submit"> <INPUT TYPE="RESET" VALUE="Clear form"></TR><BR> </TABLE> </FORM> </TD> </TR> <TR> <TD bgcolor="#FFFFFF"> <p><font color="#5684B6" size="2" face="Tahoma"><strong>As soon as we receive your registration form, we will notify you by e-mail and guide you through everything you need to do for your trip to Puebla.</strong></font></p> <p><IMG SRC="Images/registrationmain_03.gif" WIDTH=800 HEIGHT=22 ALT=""></p></TD> </TR> </TABLE>  <p><font size="2" face="Tahoma"><a href="http://www.sipuebla.com/index.htm" target="_top"><img src="index2/home.gif" width="80" height="80" border="0"></a></font></p> <p><font color="#FFFFFF" size="1" face="Tahoma"><strong>Copyright © 1984-2007 Spanish Institute<br> All Rights Reserved.</strong></font></p> </body>