Application Form for White Nights Russian 	
         Language and Cultural Immersion Program

Name:         ______________________________            									       
									     
Address:     ______________________________  
	      		
City:            ___________________________

State:          _______________ Zip _______  Country:

             Telephone Number: (    ) _______________
     Emergency contact number: (    ) _______________

Citizenship: ________  Passport Number: _________________

Age: ______    Sex: _______


Describe preferences desired for Families:
(attempts made to accommodate preferences, but no guarantees)





Describe your knowledge (if any) of the Russian language:
(speaking ability/time of previous study, etc.)






Hours of extra, individualized Russian language
                           instruction desired:


			Date selected for
  			  program start     : _____________

Airline flight number and airport or
train number and train station & 
date and time of arrival for pick-up: _____________
(failure to specify this information relinquishes White Nights
of responsibility for pick-up. Conveyance of information possible at any time
prior to arrival date.)

                                  Program end date : _____________

		        Moscow excursion: Yes ____  No ____

     Visa start date:                       Visa end date:
(select dates desired for Russian visa. Allow yourself extra time
for travel uncertainties and for reasonable additional travel in Russia besides
your stay in Saint Petersburg)






						      

Program Cost:		(4 weeks)                       2350f

Additional weeks: ___ weeks at 550f/week 	= 	____ f

          Individualized
       Russian Language  ____ hours at 14 f/hour=     ____ f
            Instruction

Optional excursion to Moscow			= 	____ f
(690f, refund given for reduction of
  services if less than three participants)

       Subtract 75f/week for each week that  (  ____ f)
        group instruction is not wanted.

         50f discount for students
 (participant obliged to bring student ID)   (  ____ f)


                                             TOTAL     ____ f

                           (minimum 500f deposit)   :  ____ f

               Balance due White Nights
           for issuance of travel voucher           :  ____ f




I have carefully read and agree to the terms in the attached
sheet describing program conditions:



                        _____________________________
                            Signature of Applicant

White Nights 
Kleine Butjesstaat 38
9712 Groningen
Netherlands

Phone (050) 314-6749

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