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Name:

Address:

City/Town:

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Email Address:

Phone Number:

Other (if not listed)

	Spanish	French	Italian	German	Chinese	Japanese	Portuguese
SPEAK (some or more)	SPEAK (some or more) Spanish	SPEAK (some or more) French	SPEAK (some or more) Italian	SPEAK (some or more) German	SPEAK (some or more) Chinese	SPEAK (some or more) Japanese	SPEAK (some or more) Portuguese
Would like to LEARN	Would like to LEARN Spanish	Would like to LEARN French	Would like to LEARN Italian	Would like to LEARN German	Would like to LEARN Chinese	Would like to LEARN Japanese	Would like to LEARN Portuguese

Other (if not listed)

Dining out as a couple and/or with friends

Going to dinner parties

Hosting dinner parties

Attending wine-tastings

Traveling

Going to the theater / opera / etc.