GOETHE-INSTITUT / MAX MUELLER BHAVAN MUMBAI

REGISTRATION FORM | LANGUAGE COURSES

✔ Mr. Mrs. Ms. Dr. Other ________________________________________

Siddharth
First Name: ____________________________
Tiwari
Surname: ____________________________________
29/10/1991
Date of Birth: ___________________________
Mumbai
Place of Birth: _______________________________
Patra Chawl, Lohiya Nagar, Room No. 10, Vile Parle west
Address: _______________________________________________________________________________________________

___________________________________________________
400056
Pincode: _____________________________________
9167462715
Mobile: __________________________
9076238907
Phone: _______________________________________________
stiwari771@gmail.com
Email: _____________________________________________________________________________________________

Knowledge of German: ✔ Yes No

B2.1 Kalaghoda March 2019
If yes, course(s) attended at: _________________________ when _________________ &

marks scored ___________________

I WISH TO ENROL IN THE FOLLOWING COURSE

Course Level: B2 Venue: Kalaghoda

Course dates: May 09- June 26 Timeslot: 1.15-5.15

Course Fee: 24300

PAYMENT DETAILS

I enclose a Demand Draft bearing no. ___________________________ for INR ____________________

(made payable to “Max Mueller Bhavan”)

24300
I am paying Cash for INR ___________________ with following specifications:

2000 _______________________________________________________________________________________________

500 _______________________________________________________________________________________________

100 _______________________________________________________________________________________________

✔ I have read and accepted the Terms & conditions of Goethe-Institut / Max Mueller Bhavan
Mumbai and I am willing to abide by the same.

07/04/2019
Date: _____________________________________

Signature: ________________________________