Consultation Preparation | Berlitz Indonesia

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Consultation Preparation

Consumer Self Assessment Form

Step 1 of 5 - My Info

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My Info
Name*
Prefix First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company
Phone 1*
Phone 2
Email*
Enter Email Confirm 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

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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:
Please specify

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11. What is your language goal?
- Basic / simple sentences
- Demanding conversations
- Complex situations
- Pass examination
- Other:
Please specify
12. Are you also interested in …
- Intercultural training
- Presentations
- Telephoning
- Correspondence
- Specialized language/ vocabulary in...
- Language trip
- Children’s Program
Please specify
Children’s years of birth

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For language center use only
Date*
FU1:
FU2:
FU3:
Current situation:
Language goal/level:
Current level:
Course materials:
Urgency:
Invoicing:
Schedule:
Program:
Other interests:
Expectations:
Comments
This field is for validation purposes and should be left unchanged.

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Berlitz Language School Indonesia

This Berlitz Language Center is independently owned and operated by PT. Bina Multi Widya

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