Online Application
Which course would you like to register for:
ESL TESLGAC
Family Name:
First Name:
English name, if you
use one:
Sex:
Male Female
Choose which location you would like to register at:
Victoria Kelowna
Birth Date
(month/day/year):
Emergency Contact:
Home Address:
Nationality:
Telephone Number:
FAX Number:
Email Address:
Type of Visa:
Student VisitorWorking
Passport# Visa#
Start Date: End Date:
Number of Term:
Homestay Application
Parents Names:
Guardians Names:
Guardians Address:
Personal Information
What are your
hobbies/interests?:
Do you wish to be placed in a
homestay home with children?
Yes
No No preference
Do you wish to be placed in a
homestay home with teenagers?
Yes
No No preference
Do you wish to be placed in a
homestay home with pets?
YesNo ...
If yes, what kind of pet?:
Do you have any special
requirements regarding your homestay placement?
Medical Information
Are you allergic to cats or
dogs?
YesNo
Please list any other
allergies, chronic illnesses or dietary restrictions:
Describe any special medication
you are taking:
If you have any health
condition which the school or your homestay
should know about, please describe it:
Do you smoke?
YesNo
Please type any additional
comments here:
This transaction of Information will be done on a
secure server.
Go back
... or you may print the forms above and mail or fax to:
Pan Pacific International College
Attention: Thaddeus K. Monckton
3rd Floor - 810 Fort Street
Victoria, B.C. Canada V8W 1H8
Fax: (250) 380-9033
EMAIL US AT
info@panpacificcanada.com
PAYMENT INFORMATION
AND BANKING ADDRESS
Payments by International Money Order, Bank Draft, Wiring Funds, Cash,
or VISA in Canadian Funds payable to:
Pan Pacific
International College Inc.
Canadian Imperial Bank of Commerce
1175 Douglas Street, Victoria, British Columbia, V8W 3R9, Canada,
Phone:(250) 356-4221 Fax: (250) 356-4372
Bank Account Number: CIBC CATT 00090-010-76-16112
The information collected on this
form is required and will be used solely for the purpose of operation of
the Panpacific International College. It will be kept secure and
confidential with the Freedom of Information and Protection of Privacy
Act.
EMAIL US AT info@panpacificcanada.com
