Homestay Application - Page 1 of 2

APPLICANT INFORMATION

Surname/Last Name:  

Forename/First Name:  

Middle:  

Date of Birth (YYMMDD):  

Address - Line 1:  

Suite/App#:  

Address - Line 2:  

Town/City, State/Province/County:  

Postcode/Zip Code:  

Country:  

Email Address:  

Mobile Telephone Number:  

Resident Telephone Number:  

Religion:  

Nationality (Passport Issued by):  

Sex:  

  Male           Female

Highest level of education obtained:  

(If education continuing, please enter level and "In progress")  

University/High School Name & Location:  

Degree obtained & date obtained/anticipated:  

PERSONAL QUESTIONS:

Is English your native language?:  

YES  NO 

If no, what is your native language?:  

Other languages spoken and level of fluency:  

1 -   

2 -   

3 -   

List any previous work experience and duration:  

(including any volunteering)  

1 -   

2 -   

3 -   

Have you ever traveled alone aboard or out of your native country?:  

YES  NO 

If YES, list Countries and Duration:  

1 -   

2 -   

3 -   

4 -   

Do you have any special dietary requirements?:  

YES  NO  If Yes, explain: 

Do you have any allergies?:  

YES  NO  If Yes, explain: 

Do you take any medications?:  

YES  NO  If Yes, explain: 

Do you drink or smoke excessively?:  

YES  NO  If Yes, explain: 

Have you had any serious injuries in the past 6 months?:  

YES  NO  If Yes, explain: 

Is there anything else relevant that ATCE should know about  

your ability to travel and Homestay?:  

YES  NO  If Yes, explain: 

Have you ever been convicted of a criminal offense?:  

(Exclude any minor traffic offenses)  

Please be honest as a Criminal Record check will be conducted  

YES  NO  If Yes, explain: 

HOMESTAY DATES:

Start date (2008)?:  

19th May to 13th June 16th June to 11th July 14th July to 8th August 11th August to 5th September Other

Proposed length of stay of Homestay?:  

1 month 2 months 3 months 4 months 5 months 6 months

Proposed length of total stay in Thailand (days):  

How did you hear about Anglo Thai Cultural Exchange?:  

Any questions, concerns or other comments?

DISCLAIMER AND SIGNATURE OF APPLICANT:  By signing electronically below, you acknowledge and certify that my answers are true and complete to the best of my knowledge; that if this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I further understand that all information is subject to verification and may be provided to third parties unassociated with Anglo Thai Cultural Exchange including being used for Criminal Background Checking and provided to the Homestay family and schools.  Data Protection Act – I hereby allow Anglo Thai Cultural Exchange, Ltd to send a limited amount of my application past the border of the European Economic Area.

Name:  

Date of Application (YYMMDD):