Please answer all required fields (marked with * ) then Submit Application

*Full Homestay (Breakfast & Dinner) B&B (Breakfast)

*Number of Student bedrooms available:

*First Name: *Last Name:

*Occupation/Employer:

*Date of Birth: / / 19 (month/day/year)

Spouse First Name: Spouse Last Name:

Spouse Occupation/Employer:

Spouse Date of Birth: / /19 (month/day/year)

*Address:

*Postal Code: *City: *State: Country: USA

*Telephone: Cell Phone: *Email:

*Religion: *Hobbies/Interest:

Other household members & ages:

Your Home Environment (check all that apply)

Private bedroom: Private bath: Share bath:   Breakfast: Dinner: Kitchen Access:

*Student Preference: Male Female No preference:

*Will you accept a student that smokes? Absolutely not Outdoor smoker only   No preference

Check your Preferences:

*Family type: Couple Single Family with children   *Pets: Dogs Cats No Pets   *Do you or your Family smoke? Yes No   *Do you or your Family drink alcohol? Yes No

*Distance from bus stop: (Yard or Miles) Bus#:

*Does the bus run on Saturdays & Sundays?Yes No  If no weekend service, would you give a ride to train station? Yes No

*Closest Marta station:

Travel time to Marta station: (Mins)

* I understand that Atlanta Homestays is not responsible for my health or safety while hosting a Homestay Student.

Date: