Please provide the following contact information:

Name
Nationality
Name of University /School studying in Australia ?	Name   Which State ?    Course of Study
Mobile Phone Number
E-mail Address
Education Agent Email Address (If Applicable)

Date of Birth
Gender	Male Female

A home with Children ?         With Children       Without Children         Either  

                                                            
Do you Smoke ?     No         Yes                           

Do you like Pets  (Dogs & Cats) ?  No Pets        With Pets     Either

Airport Transfer Required ?     Yes       No    

Please advise your flight details if you have them. If you do not require Airport Transfer your flight details are required so as your homestay can be informed.

Date       Time       Flight Number 

Accommodation Start Date : -- dd/mm/yy

Special Requests ? 

I agree to the conditions of Homestay Australia P/L as specified in the section "HOMESTAY CONDITIONS".       YES