Name:

Host Nationality:

Address:

Zone:

Tel:

Mobile:

E-Mail:

Host Occupation:

Pets:

Smoke:

Internet:

Type of Accommodation:

Single:

Twin:

Triple:

How many students could you accommodate at any one time?

Details of other people in household:

Name

Age/Sex

Relationship

Occupation

NEAREST STATIONS:

Line

Name

Journey

Distance

How many students have you hosted in the past?