Please type or print legibly in black ink, so that these forms can be photocopied.
Answer all questions. Please complete this application as honestly as possible.
Our organization will use this information to select your host family.
| Legal name (as it appears on your passport)
Last name: __________________________
First name: _________________________
Middle name: _______________________
Sex: Male Female
Zip Code/Postal Code: ___________________
Home Fax: ____________________________
| Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec _____________
Month (circle one) Day Year
Place of Birth: __________________________________________________________________
Country of Citizenship: ______________Country of Permanent Residence: