Your details Title * - Select -MrMrsMsMiss Family Name * First Name * Nationality Mother tongue Date of birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Current employment Home address Postcode Telephone Email * How did you hear about Saint George International? - None -InternetBritish CouncilBTAPersonal RecommendationSGI Representative (please give details)Other (please give details) Please give details Secondary Education School Subjects/Grades at A level Further Education / Training(Please provide a copy of any certificate) University/College Subjects/Grades Other (Please give details) Current or last teaching position Name of DOS / Academic manager are / were responsible to ... and who can support your application and verify that you are/were employed at the school N.B This is a requirement of the revised Diploma syllabus. Name and full address of the school E-mail Telephone Other refereePlease give one further referee to support your application Name Address E-mail Telephone Languages Spoken1=basic, 3=fair, 5=fluent Language Oral Competence - None -12345 Written Competence - None -12345 Language Oral Competence - None -12345 Written Competence - None -12345 Language Oral Competence - None -12345 Written Competence - None -12345 Language Oral Competence - None -12345 Written Competence - None -12345 Please write briefly why you would like to take the DIPLOMA and why the Saint George’s Distance Training Programme appeals to you Initial TESOL qualification(Please provide a copy of any certificate) Qualification Training Institute Date of Award Grade English language qualification (for non-native speakers) Qualification Training Institute Date of Award Grade English teaching experience ( from past to present) Institution/Country Start date End date Av. no. of contact hours Student age ranges and levels taught Institution/Country2 Start date2 End date2 Av. no. of contact hours2 Student age ranges and levels taught2 Institution/Country3 Start date3 End date3 Av. no. of contact hours3 Student age ranges and levels taught Institution/Country4 Start date4 End date4 Av. no. of contact hours4 Student age ranges and levels taught Start and examination datesThese do not become fixed dates for you. They are intended as a guide for us and a focus for you. Please give month and year. When do you want to start your DISTANCE TRAINING PROGRAMME? When do you want to do the final WRITTEN EXAM? When do you want to do the PRACTICAL EXAMS & the PRACTICAL BLOCK? How to pay Once accepted on the course, I wish to pay by Credit card Sterling cheque Payment by Bank Transfer to: Svenska Handelsbanken AB (publ) London Branch Trinity Tower 3 Thomas More Street London E1W 1WY United Kingdom Account Name: St George International Account Number: 28859001 Branch Code: 40 - 51 - 62 Swift Code: HANDGB22 IBAN Number: GB32HAND40516228859001 Payment / Refund Policy Please note that for students who have started their course and have received their initial workbooks no refund can be made on tuition fees. Once course fees are paid, students have two years to complete their course, based on the month of starting. e.g start month, September 2012: latest finish month, September 2014. On a discretionary basis, a one year extension to the course can be agreed with SGI. Currently this extension fee is £180. Additional information? Please add any extra information here What code is in the image? * Enter the characters shown in the image.