Please provide the following Student information:

Name of Agent
Agent's Email Address
School	Name                   Course                Which State        Country
Applicant's Name
Applicant's Nationality
Applicant's Mobile Phone Number	Applicant's Skype Address
Applicant's Email Address

Applicant's Date of Birth
Gender	Male Female

 

 First Period in Homestay :  1 Week      2 Weeks      3 Weeks        4 Weeks

Meals :

Does the Applicant require -

    3 Meals per day (Breakfast Lunch and Dinner)        

    2 Meals (Breakfast and Dinner, Monday to Friday ; 3 Meals (Breakfast, Lunch and Dinner, Saturday and Sunday) 

    2 Meals per day (Breakfast and Dinner, 7 days per week)        

   Breakfast Only           

    No meals provided 

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Shared Room Application : 

     Start Date     Number of Weeks

    Applicant 1(Name)           Date of Birth      Gender       Nationality 

    Email Address      School 

   Applicant 2 (Name)            Date of Birth      Gender       Nationality 

    Email Address      School 

    Meal Plan : 2 meals (Breakfast and Dinner each day)                  Breakfast Only each day         No Meals Provided     

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Does the Applicant require  - A home with Children ?         With Children       Without Children         Either  

                                                            
Does the Applicant like Pets  (Dogs & Cats) ?  No Pets        With Pets     Either

Does the Applicant require Airport Transfer   Yes       No    

Please advise your flight details if you have them. If  the Applicant does not require Airport Transfer we still require the flight details so as the Host can be informed.

Date       Time       Flight Number 

Accommodation Start Date : -- dd/mm/yy

Halal Meals required ? Yes No

Are you coming to Australia with other members of your family ?   If so whom ?

Any Special Requests ? 

The Agent agrees to the conditions of Homestay Australia PL as specified in the section HOMESTAY CONDITIONS   YES