Name :

First Middle Last

Email address
Email address (confirm)
Gender Male Female
Passport Number
Social Security Number
Birth date :

mm/dd/yyyy ie (02/06/1982)

Address Street
City
State
Country

Person to contact in case of emergency:

Name
Address Street
City
State
Country
Telephone

Current place of education and/or employment :

Institution / company name
Address Street
City
State
Country
Telephone
Major Subject or Occupation

References from school or employer (2 referees required) :

Intended start date: mm/dd/yyyy ie (02/06/1982)
Length of term of placement that you are interested in ? Years Months Weeks Days
Location of placement that you are interested in? Japan United States Australia Thailand Nigeria China Mexico

Language abilities
English ----- None Basic Intermediate Advanced Fluent
Japanese ----- None Basic Intermediate Advanced Fluent
Spanish ----- None Basic Intermediate Advanced Fluent
Chinese ----- None Basic Intermediate Advanced Fluent
Thai ----- None Basic Intermediate Advanced Fluent
French ----- None Basic Intermediate Advanced Fluent
Other (please specify):
----- Basic Intermediate Advanced Fluent

Personal Information:

Active Cheerful Independent Optimistic
Quiet Shy Sociable Talkative

Do you like animals (cats and dogs)? --- Yes No
Do you like children? --- Yes No
Do your smoke? --- Yes No
Do you drink alcoholic beverages? --- Yes No
Previous trips abroad? --- Yes No What country(ies) did you visit?

Medical Condition:

Do you have allergies? --- Yes No
If yes, what are you allergic to?
Please list any medications which you are presently taking
Do you have restrictions to your diet? (ie vegan, vegetarian, etc..) --- Yes No
If yes, please list briefly your diet restrictions

Please list any other medical conditions or conditions that may affect your living environment that could affect your stay

I hereby swear that the above information is correct and accurate. I proclaim to be the above person and am not giving anybody else's information.

After submitting this form online, please mail a copy of your passport, 2x passport-sized photos and include a US$100 dollar processing fee* in the form of a money order made payable to:

Kozmoz International
703 e39th ave.
Spokane WA 99203 U.S.A

Enquire here to pay online.

*Please note the fee is non-refundable and does not guarantee you a placement. Kozmoz International assumes no liability or responsibility between you and your prospective host family and serves only to introduce you to interested parties as they are available. Any and all agreements with regards to extra fees, house rules, allowable and non-allowable activities, curfews, meals, living arrangements etc. are to be negotiated between you and prospective host families directly. The basic fee for a homestay with 2 meals per day is 500 dollars U.S. per month. Student should be prepared to pay first month, last month and a security deposit of 100 dollars U.S in advance. All and any agreements should be in writing and no change should occur with less than 30 days written notice.

 

Please write any questions or opinions here: