English Language + Literacy Application - LearningWorks

Name*

First Last

Birth Date

MM

DD

YYYY

Address

Street Address Address Line 2 City ZIP Code

Email

Phone

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?*

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