Order Form

Enter your name and age:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female

Please, provide the following contact information:

Title
Organization
Home Phone
FAX
E-mail
URL

When do you plan to visit Ukraine/Russia: -- mm/dd/yy

Where do you prefer to stay:   Hotel Rent Apartment Stay with Ukrainian Family I don't need this service

What is a purpose of your visit:

• Tourism or business

  • How long are you going to stay in Ukraine/Russia:

    up to 10 days

    up to 2 weeks

    up to 1 month

    longer than one month

  • What cities you would like to visit during your visit?

    Kharkiv

    Kyiv

    Lviv

    Dnepropetrivsk

    Mariupol

    Odesa

    Yalta

    Other cities or places of Ukraine

• Language courses

  • How long are you going to attend courses:

    1 month
    2 months
    3-5 months
    6-10 months

  • Language(s) you'd like to learn:          

    Russian  Ukrainian   

• Please, send me pricing information for the services I've requested.  

  • I prefer to make a payment by:

    Visa/Mastercard, other card from Chumak List (see below)

    Money Order/Cheque

    Bank Payment 

    Western Union Payment 

     

Please, give any additional information