Please provide the following contact information:

Name
Nationality
University /School	Name                  Course  Which State       Country
Mobile Phone Number	Skype Address
E-mail Address

Date of Birth
Gender	Male Female

 Meals : Three (3) Meals per day           Two (2) Meals per day          Breakfast Only           No meals provided 

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

Do you require a Halal Homestay ? Yes No         

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

Any Special Requests ? 

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