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ENGLISH IN THE VACATION 31 August - 22 September 2005, University of Sussex, Brighton. APPLICATION FORM To apply please complete this form in BLOCK CAPITALS and send it together with the appropriate fee by 30 June 2005 to: Prof. L. Löb Director English in the Vacation School of Humanities University of Sussex Brighton, BN1 9SH United Kingdom Surname and given name........................................….............................… ....................................…......................................................….................… Sex .................................................... Date of birth ..................................... Nationality .................................................................................................… Native language .......................................................................................... Home university .......................................................................................…. ....................................................................................................................… Year of university study ................................................................................ Any degrees or diplomas held, examinations passed ..................................... ................................................................................…....................................... Any examinations to be taken in near future nature of examination ....................................................................................... date of examination .................................................…...................................... Earlier stays in English-speaking countries number of visits ...................... total time spent .................................................. nature of visits .................................................................................................... ................................................................................…......................................... Do you wish to be wait-listed if the course is fully booked? ................................. Address (with phone and fax number and e-mail address if available) ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ I enclose cheque (drawn on a UK bank) /Postal Order for the deposit of £120, payable to University of Sussex / I authorise the University of Sussex to debit the following Visa/Mastercard with the deposit of £120 (please delete as appropriate). For Visa/Mastercard Number .............................................................. Expiry date ........................... Name and address of cardholder if different from applicant ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... Signature of cardholder .......................................... Date ..................................
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