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Consumer Self Assessment Form
Step 1 of 5 - My Info
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My Info
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
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Guinea-Bissau
Guyana
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Hungary
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Iraq
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Italy
Jamaica
Japan
Jordan
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Kiribati
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Kuwait
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Latvia
Lebanon
Lesotho
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Libya
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Lithuania
Luxembourg
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Mauritius
Mexico
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Mongolia
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Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
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Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
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Portugal
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Spain
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Sudan, South
Suriname
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Sweden
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Taiwan
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Tonga
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Tunisia
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Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
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Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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Company
Phone 1
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Phone 2
Email
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1. Which language do you wish to learn?
*
2. How would you rate your language skills?
*
Absolute beginner
Basic knowledge
Can make myself understood
Converse fairly well
Quite fluent
3. Will you be using the language in your profession?
*
Yes
No
4. How many hours per week can you devote to language training?
*
5. How long does it take you to travel from home to Berlitz?
*
6. What is your educational background?
*
Grade school
High School graduate
Some College
College graduate
Post graduate studies
7. What is your current employment status?
*
Employed full-time
Employed part-time
Temporarily unemployed
Student
Homemaker
Retired
8. In which type of business do you work?
*
Banking / Finance
Business Services
Communications
Education
Energy
Government
Health/ Medical/ Pharmaceutical
Import / Export
Legal/ Criminal/Justice
Retail/Wholesale
Travel/ Transportation
Textiles/ Manufacture
Cosmetics / Fragrances
Electrical/ Plumbing/ Equipment Manufacture
Food Products
Tobacco Products
Other:
Please specify
We would be grateful if you could provide the following information for our statistics:
Age
Under 18
18-24
25-29
30-34
35-40
41-49
50-59
60+
Marital Status:
Married
Single
No Answer
9. If you have children, what are their birth years?
10. What is your occupation?
Professional
Technical
Business Executive/ Manager
Sales/Marketing
Clerical/Customer Service
Teacher/Professor
Public Official / Administrator
Public Services
Self-Employed/Business Owner
Tradesman/Factory Employee
Artist
Service Professional
Other:
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11. What is your language goal?
Basic / simple sentences
Demanding conversations
Complex situations
Pass examination
Other:
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12. Are you also interested in …
Intercultural training
Presentations
Telephoning
Correspondence
Specialized language/ vocabulary in...
Language trip
Children’s Program
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Children’s years of birth
For language center use only
Date
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FU1:
FU2:
FU3:
Current situation:
Language goal/level:
Current level:
Course materials:
Urgency:
Invoicing:
Schedule:
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Other interests:
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