English Language + Literacy Application - LearningWorks

Name*

First Last

Birth Date

MM

DD

YYYY

Address

Street Address Address Line 2 City ZIP Code

Email Address

Home Phone

Cell Phone

What is the best way to reach you?

What service do you need? (You can check more than one):*

English Language Class
1-on-1 Tutoring

Check one. I am a:

Where are you from?*

What is your primary language?

When did you arrive in the U.S.A?

MM

DD

YYYY

When did you arrive in Maine?

MM

DD

YYYY

Check your answer. In my home language, I can:

read
write
speak

Are you working?

Yes
No

If yes, where?

Choose your answer. In my country I finished…

What is your English level?

Are you taking classes at another place?

Yes
No

If yes, where?

When are you free to take classes or meet with a tutor?

What day of the week are you free to take classes or meet with a tutor?

How did you find us?

Please specify other

Referring Person/Organization

Phone Number

Email

For questions or to make or speak about a referral, contact the English Language and Literacy program at (207) 775-0105 ext. 165 or fax (207) 775-1932

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First Choice
Second Choice
Third Choice

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