Preliminary Enrolment Form

Personal Data
Name:
Surname:
E-mail:
Telephone:
Preferred date/start time for one-to-one tutoring
Day of the week or date (Mon-Sun or 01-31):	MondayTuesdayWednesdayThursdayFridaySaturdaySunday01020304050607080910111213141516171819202122232425262728 FebruaryMarch 2010
Start time (your local time, 24-hour clock, from 00:00 to 23:55) :	h. 000102030405060708091011121314151617181920212223 m. 000510152025303540455055
Major world city in your time zone:	Addis AbabaAdelaideAdenAlgiersAlmatyAmmanAmsterdamAnadyrAnchorageAnkaraAntananarivoAsuncionAthensAtlantaAucklandBaghdadBangkokBarcelonaBeijingBeirutBelgradeBerlinBogotaBostonBrasiliaBrisbaneBrusselsBucharestBudapestBuenos AiresCairoCanberraCape TownCaracasCasablancaChatham IslandsChicagoCopenhagenDarwinDenverDetroitDhakaDubaiDublinEdmontonFrankfurtGenevaHalifaxHanoiHarareHavanaHelsinkiHong KongHonoluluHoustonIndianapolisIslamabadIstanbulJakartaJerusalemJohannesburgKabulKamchatkaKarachiKathmanduKhartoumKingstonKiritimatiKolkataKuala LumpurKuwait CityKyivLa PazLagosLahoreLimaLisbonLondonLos AngelesMadridManaguaManilaMelbourneMexico CityMiamiMinneapolisMinskMontevideoMontgomeryMontrealMoscowMumbaiNairobiGuatemalaNassauNew DelhiNew OrleansNew YorkOsloOttawaParisPerthPhiladelphiaPhoenixPragueReykjavikRio de JaneiroRiyadhRomeSan FranciscoSan JuanSan SalvadorSantiagoSanto DomingoSao PauloSeattleSeoulShanghaiSingaporeSofiaSt. John'sSt. PaulStockholmSuvaSydneyTaipeiTallinnTashkentTegucigalpaTehranTokyoTorontoVancouverViennaVladivostokWarsawWashington DCWinnipegYangonZagrebZürich
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Pursuant to Italian legislative decree N° 196 of 30 June 2003 regarding personal data protection, I hereby authorize Michael Farrell to use the data sent in order to organize the requested event.

Furthermore, I hereby declare that I have read the privacy policy (information to data subjects pursuant to section 13 of Italian legislative decree N° 196/2003).

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