HOMESTAY APPLICATION

(You must fill in those blanks with the red marks)
1
*Name
Mr.
Ms.
First Name:
Middle Name:
Family Name:
2
*Date of Birth
Day: Month: Year:
3
*Nationality
4
*Religion
5
*Occupation
6
*What is your native language?
7
*What is your english conversational ability?
(Select one)
Low
Intermediate
Advanced
8
*Current Address
TEL:
E-mail:
9
Permanent Address(Only when it is different from current address)
10
*Would you prefer a family which has a pets?
Yes
No Preference
No
11
*If no, which animals are you unable to live with?
Dog
Cat
Other()
12
*Do you smoke?
Yes
No
13
If you smoke, how often do you smoke a day?
14
*Would you prefer a family with small children?
Yes
No Preference
No
15
Please list any health problems, allergies or foods that you cannnot eat
16
Have you been Japan before?
17
What are your hobbies or special interests?