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PERSONALPleaseprovideyourpersonalinformation.Typeorprintyournameexactlyasitappearsinyourpassport.LastFamilyNameFirstGivenNameMiddleNameMaleFemaleAgeDateoBirthMonthDayYearNationalityNativeLanguageMailingAddressCityProvincePostalCodeCountryTelephoneNumberincludeareacodeEmailThankyouorchoosingaUCRhomestayamilyThisormmustbereceivedatleast4weeksbeoreyourarrival.Wecannotguaranteethatyouwillbeplacedinahomethatsatisfesallyourpreerencesiyouwantthebestchancetomeetyourrequestssubmitanapplicationearly.PROGRAMPleaseidentifytheprogramforwhichyouveappliedandyourexpecteddatesofstayQuartere.g.WinterYeare.g.2015ProgramNamee.g.APPLengthe.g.9monthsStartDateMonthDayYearMove-InDateMonthDayYearMove-OutDateMonthDayYearApplicationwillnotbeprocessedwithoutmove-inmove-outdates.1.WhowouldyoulikeustocontactincaseofanemergencyEmergencyContactPersonEmergencyTelephoneNumberEmergencyEmailAddress2.AreyousponsoredbyanagencyembassypartneruniversityYesNoINOskiptoHOUSING.IYESpleaseprovideNameoAgencyEmbassyorPartnerUniversityAgencyIDCountryContactPersonTelephoneNumberEmailAddressPleasemailfaxoremailyourapplicationmaterialstoInternationalEducationProgramsUCRiversideExtension1200UniversityAve.RiversideCA92507-4596U.S.A.Phone1-951827-4346Fax1-951827-5796Emailiepapplicationucx.ucr.eduForofceuseonlySIDProgramReceivedYoumustinormusoyourarrivalinormationinadvance.Iyourplanschangeyoumustcontactusimmediately.ReadunderstandtheHomestayStudentHandbookbeoreyouarrivehttpwww.iep.ucr.eduhandbookpd.HomestayFeesarelistedonpage19.TheyincludeaDOUBLE-occupancyroomand3mealsperday.Youmayberequiredtomakeyourownbreakastandlunchwithoodprovidedbytheamily.TheamilyisresponsibleormakingyourdinnerandortransportationtoandromUCRiversideExtensionoruniversity-sponsoredeventsandclasses.TheHomestayFeemustbepaiddirectlytotheamily.PAYMENTPayyourapplicationfeeswithacashierscheckmoneyordermadepayabletoUCRegentsorbyVisaorMasterCard.CreditCardNumberCardholdersNameExpirationDate3-DigitSecurityCodeAuthorizingSignatureIauthorizeUCRtocharge200HousingPlacementFeeOtherORMoneyOrderorCashiersCheckenclosedREQUIREDIcertiytheinormationonthisentireormiscorrecttothebestomyknowledge.SignatureDateOff-CampusHousingHomestayApplicationHOUSINGWewanttomakethebestpossiblematchforyouwithyourhomestayfamily.Pleasecompletethisbriefevaluation1.DoyousmokeYesNoNoteSmokingisNOTpermittedinthehouse.2.WouldyoupreeraamilywithchildrenYesNoNopreerence3.Arethereanyoodsyouwillnoteat4.WhatareyouravoriteoodsDoyouhaveanyallergiesoodsmedicinesthatmakeyousickYesNoIyespleaselistthem5.YourinterestsYourpersonality6.MostAmericanamilieshavepets.MayweplaceyouinaamilythathascatsYesNoNopreerenceMayweplaceyouinaamilythathasdogsYesNoNopreerenceNoteIyouanswerNOtoanyothequestionsaboveitmaytakelongertofndyouahomestay.Wemakeeveryeorttoaccommodateyourpreerencesbutthereisnoguaranteewewillbeabletodoso.7.TellusaboutyouramilyNameAgeRelationshipOccupation8.PleaseattachaphotographoyourselandalettertoyourAmericanamilytoyourapplication.