Australia      New Zealand      Canada

Name   :        D.O.B. :        
Sex : male female
Marital Status : Married      Unmarried      Divorced      Engaged      None

English level attained:
Do you hold a Certificate of IELTS or TOEFL? Yes No

If yes, please complete the table below:

Course preference:

Have you had a visa cancelled? Yes No

Where did you hear about Pacific Immigration Consultants?
Newspaper Radio Television School/College seminar Friend
Education Fair Other (specify)

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