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<div class="row">
<div class="medium-6 small-12 columns"><label> Full Name <span style="color:red;font-weight:bold;">*</span> <span class="wpcf7-form-control-wrap your-name"><input type="text" name="your-name" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
<div class="medium-6 small-12 columns"><label> Date of Birth <span style="color:red;font-weight:bold;">*</span> <span class="wpcf7-form-control-wrap your-dob"><input type="date" name="your-dob" value="" class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date" aria-required="true" aria-invalid="false" /></span> </label></div>
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<div class="row">
<div class="medium-4 small-12 columns"><label> Email <span style="color:red;font-weight:bold;">*</span> <span class="wpcf7-form-control-wrap your-email"><input type="email" name="your-email" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email" aria-required="true" aria-invalid="false" /></span> </label></div>
<div class="medium-4 small-12 columns"><label> Your Mobile <span style="color:red;font-weight:bold;">*</span><span class="wpcf7-form-control-wrap your-mobile"><input type="text" name="your-mobile" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
<div class="medium-4 small-12 columns"><label> Your Phone<span style="color:red;font-weight:bold;">*</span> <span class="wpcf7-form-control-wrap your-phone"><input type="text" name="your-phone" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
</div>
<div class="row">
<div class="medium-12 small-12 columns"><label> Home Address <span style="color:red;font-weight:bold;">*</span><span class="wpcf7-form-control-wrap your-address"><input type="text" name="your-address" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
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<div class="row">
<div class="medium-12 small-12 columns"><label> Course  <span style="color:red;font-weight:bold;">*</span>( Please tick relevant )<br />
<span class="wpcf7-form-control-wrap your-course"><select name="your-course" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="Life in the UK Test Preparation">Life in the UK Test Preparation</option><option value="B1 Test">B1 Test</option><option value="UK Driving Theory Test Prep">UK Driving Theory Test Prep</option><option value="A2 Test">A2 Test</option><option value="Other">Other</option></select></span> </label></div>
</div>
<div class="row">
<div class="medium-6 small-12 columns"><label> Fee Life in the UK Test  <span style="color:red;font-weight:bold;">*</span><br />
<span class="wpcf7-form-control-wrap your-fees-life-uk"><select name="your-fees-life-uk" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="£250 until first Exam">£250 until first Exam</option><option value="£300 until PASS">£300 until PASS</option></select></span> </label></div>
<div class="medium-6 small-12 columns"><label> Driving Theory Test<br />
<span class="wpcf7-form-control-wrap your-fees-driving-theory"><select name="your-fees-driving-theory" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="£250 until first Exam">£250 until first Exam</option><option value="£300 until PASS">£300 until PASS</option></select></span> </label></div>
</div>
<div class="row">
<div class="medium-6 small-12 columns"><label>  B1 / A2 Test  <span style="color:red;font-weight:bold;">*</span><br />
<span class="wpcf7-form-control-wrap your-fees-b1a2"><select name="your-fees-b1a2" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="£150 until first Exam">£150 until first Exam</option><option value="£200 until PASS">£200 until PASS</option></select></span> </label></div>
<div class="medium-6 small-12 columns"><label> Other<br />
<span class="wpcf7-form-control-wrap your-fees-other"><input type="text" name="your-fees-other" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
</div>
<div class="row">
<div class="medium-12 small-12 columns"><label> I would apply for  ( Please tick relevant ) <span style="color:red;font-weight:bold;">*</span><br />
<span class="wpcf7-form-control-wrap your-applyfor"><select name="your-applyfor" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="Citizenship">Citizenship</option><option value="ILR ( Indefinite Leave to Remain)">ILR ( Indefinite Leave to Remain)</option><option value="Spouse visa extension">Spouse visa extension</option><option value="N / A">N / A</option></select></span> </label></div>
</div>
<div class="row">
<div class="medium-12 small-12 columns"><label> Current Job / study Any other relevant  <span class="wpcf7-form-control-wrap your-currentjob"><input type="text" name="your-currentjob" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></div>
</div>
<div class="row">
<div class="medium-12 small-12 columns"><label> Where did you hear about us? <span style="color:red;font-weight:bold;">* </span>   <span class="wpcf7-form-control-wrap how-hear"><select name="how-hear" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false"><option value="Google">Google</option><option value="Whats message, Text message, Viber message">Whats message, Text message, Viber message</option><option value="Social media ( Facebook, Youtube">Social media ( Facebook, Youtube</option><option value="Flyer (Door)">Flyer (Door)</option><option value="Flyer (Mosque)">Flyer (Mosque)</option><option value="Friend referral">Friend referral</option><option value="X-Student">X-Student</option><option value="Road sign">Road sign</option><option value="Shop banner">Shop banner</option><option value="Others">Others</option></select></span> </label></div>
</div>
<div class="row">
<div class="medium-12 small-12 columns"><label> I would apply for  ( Please tick relevant ) <span style="color:red;font-weight:bold;">*</span><br />
<span class="wpcf7-form-control-wrap your-chekbox"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first last"><input type="checkbox" name="your-chekbox[]" value="Please tick this box if you would like to receive* information about courses from eHouse Leeds. Please tick this box if you give us permission to use your picture in eHouse marketing material.Terms &amp; Conditions" /><span class="wpcf7-list-item-label">Please tick this box if you would like to receive* information about courses from eHouse Leeds. Please tick this box if you give us permission to use your picture in eHouse marketing material.Terms &amp; Conditions</span></span></span></span> </label></div>
</div>
<h3>Terms & Conditions</h3>
<p>Course fee must be paid in advance or on the date of registration of the course.<br />
Course cancellation or day (s) cancellation by Education House Leeds because of unseen reasons is not refundable.<br />
Any student who abandons classes after the commencement of the course will not be entitled to refund of the fees paid.<br />
Registration fee is non refundable but it is adjustable in the total fee of the course (s).<br />
I, declare information I have given in this form is correct. I further certify that I have read, understood and agree to comply with the terms and conditions of the registration mentioned above. </p>
<p>Education House Leeds 5-11 Hares view LS8 4LG<br />
Bankers  > HSBC > Sort Code: 40-27-15 > Account Number: 95067413</p>
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