HOMESTAY REGISTRATION FORM

1. PLEASE NOTE! ALL INFORMATION IS STRICTLY CONFIDENTIAL AND IT IS NOT DISCLOSED OR SOLD TO ANY THIRD PARTIES.
   THE CONFIDENTIALITY OF OUR CLIENTS AND REGISTERED HOMESTAYS IS OF THE UTMOST IMPORTANCE TO US AND OUR CLIENTS.

SURNAME
MIDDLE NAME
FIRST NAME
HOME ADDRESS	TOWN/CITY
PROVINCE/TERRITORY	POSTAL CODE  COUNTRY
HOME TEL. NO.
CELL NUMBER
E-MAIL ADDRESS	（CONFIRM E-MAIL）
DO YOU OWN YOUR HOME ?	YES NO RENT OTHER/EXPLAIN その他
TYPE OF DWELLING	HOUSE  CONDOMINIUM  DUPLEX  FARM  OTHER
PLACE OF EMPLOYMENT
POSITION	OTHER:
EMPLOYER'S ADDRESS
CITY/TOWN
POSTAL CODE	COMPANY E-MAIL:
DO YOU OWN A CAR ?	YES  NO   YEAR: MAKER:MODEL:
	PLATE NUMBER
LANGUAGE SPOKEN
ENGLISH	NATIVE  FLUENT  CONVERSATIONAL  BASIC  NONE
FRENCH	NATIVE  FLUENT  CONVERSATIONAL  BASIC  NONE
MARRIED	YES  NO  *OTHER
CHILDREN	YES  NO  *NUMBER OF CHILDREN
PETS	YES  NO  *IF YES, WHAT KIND OF PETS ? AND HOW MANY?
TYPES OF HOMESTAYS
PLS. CHECK THE TYPES OF HOMESTAY PROGRAMS THAT YOU'RE INTERESTED IN ?	DAILY  WEEKLY  MONTHLY  EXTENDED STAY  MORE THAN SIX MONTHS
COMMENT
Anti-Spam	（Type the numbers.）  I want to be sure that you are not a robot.Please type the same numbers you see in this image into the box.

PLEASE NOTE!!!!

1. OUR CLIENTS ARE ADULTS AND CHILDREN FROM ELEMENTARY SCHOOL UP TO UNIVERSITY.
2. ALL HOMESTAYS WILLING TO ACCEPT MINORS AND YOUNG ADULTS MUST GO THROUGH AN EXTENSIVE SECURITY CHECK,
   AND WILLING TO SIGN A RELEASE FORM FOR COMPANY NAME TO DO CRIMINAL BACKGROUND CHECK, CREDIT CHECKS.
3. ALSO, THERE WOULD BE A SEPARATE APPLICATION FORM THAT WOULD NEED TO BE COMPLETED.

- SHERINA英会話 -