Complete this form (or download the PDF version) and Email or fax to:
miriamdifiore@hotmail.com
TEL/FAX: +39 0383 892114

Course Title: _______________________________________________________

Name: ____________________________________________________________

Complete Address: __________________________________________________

__________________________________________________________________

Country: __________________________________________________________

Email: ____________________________________________________________

Phone: ____________________________________________________________

Age: (just for the organization of the accomodation) _______________________

Special feeding needs (diet or allergies): ________________________________

__________________________________________________________________

Please, sign if you don't eat something of the following list:

___ Fish
___ Seafood
___ Rabbit
___ Pork
___ Lever (from cow, chicken or goose)
___ Caw Milk Cheese
___ Sheep Milk Cheese
___ Goat Milk Cheese

Please include as an email attachment:

1. A digital image of one of your recent work (the file should not exceed 500 Kb)
2. A brief description of your experience in glass.
3. A brief description of what you want to get from the course.

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