Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Country

(###)

###

####

Other Phone

Country

(###)

###

####

Expiration Date *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone 1

Country

(###)

###

####

Emergency Contact Phone 2

Country

(###)

###

####

I agree to the following terms and conditions *

The above information is true and correct. The final payment deadline is 15 March 2018. Refund policy: 100% before 4 June 2018; 80% before 5 June 2017; 50% before 6 June 2017. Costs associated with refunds, such as credit card or banking fees, will not be refunded. Nagasaki International University reserves the right to cancel the program, in which case a full refund will be provided.

I agree