Student Name *
Nationality *
Date of Birth: *
Email Address: *
Gender *	Male Female
What School/University you are attending in Australia? (full address) *
What are your interests? *
Address in home country :: *
Mobile number
Emergency contact person
Do you require Airport Pickup? *
Arrival Date, Time &; Flight Number
Accommodation Start Date *
How many weeks do you want homestay *
Present English level *	Beginner Intermidiate Advanced
Do you prefer a Family? *	With Children Without Children Doesn't Matter
Are you willing to live with a family that has pets? *	Yes No
Do you have any allergies?
Do you have any dietary problems? *
Do you smoke? *	Yes No
Bank Transfer or Bank Cheque --Bank name: Commonwealth Bank- Queen street BranchAccount name: Homestay Direct Pty Ltd BSB No:. 063 003 Account No: 10124935Please note $20 fee applies for International bank transfer only. Please add this amount total *	VIP Homestay Full Board – breakfast & dinner – lunch on weekends only--VIC $350 per week x 4 weeks $1400.00 VIP Homestay Full Board – breakfast & dinner – lunch on weekends only--NSW $365 per week x 4 weeks $1460.00 VIP Homestay Full Board – breakfast & dinner – lunch on weekends only--QLD $325 per week x 4 weeks $1300.00 Classic Homestay Full Board – breakfast & dinner – lunch on weekends only VIC $240 per week x 4 weeks $960.00 Classic Homestay Full Board – breakfast & dinner – lunch on weekends only NSW $250 per week x 4 weeks $1000.00 Classic Homestay Full Board – breakfast & dinner – lunch on weekends only QLD $220 per week x 4 weeks $880.00 Classic Homestay Part Board– no meals VIC $185 per week x 4 weeks $740.00 Classic Homestay Part Board– no meals NSW $205 per week x 4 weeks $820.00 Classic Homestay Part Board– no meals QLD $185 per week x 4 weeks $740.00
Visa or Mastercard Please note a 2% surcharge applies to all credit card
Card No Name on Card Amount and Expiry Date
Bank Transfer or Bank Cheque --Bank name: Commonwealth Bank- Queen street Branch BSB No: 063 003 $20 fee applies for International bank transfer