Prime Host Second Host Address Household Preferences Children Pets
Room 1 Room 2 Room 3 Location Photographs Agreements & References
PRIME HOST
First Name
Last Name
Email
Occupation
Gender
Select Value
Male
Female
Home Tel
Work Tel
Cellular
SECOND HOST
First Name
Last Name
Occupation
Relationship
Select Value
husband
wife
boy friend
girl friend
brother
daughter
son
sister
mother
father
cousin
niece
grand father
grand mother
Cellular
PRIME HOST - HOME ADDRESS
Street
City
Province/State
Country
Select Value
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore/Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Baker Island
Bangladesh
Barbados
Bassas da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
CANADA
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic
Congo, Republic
Cook Islands
Coral Sea Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern/Antarctic
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island/ McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Howland Island
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Jan Mayen
Japan
Jarvis Island
Jersey
Johnston Atoll
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kingman Reef
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Man, Isle of
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Midway Islands
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Navassa Island
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palmyra Atoll
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent/Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/South Islands
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
U.K
U.S.A
US Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Wake Island
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
Zip/Postal Code
Prime Host Second Host Address Household Preferences Children Pets
Room 1 Room 2 Room 3 Location Photographs Agreements & References
HOUSEHOLD
Home Condition
Select Value
Good Condition
fairly new
newly renovated
Adults
Select Value
one
two
three
four
Children
Select Value
none
one
two
three
four
five
Students
Select Value
none
one
two
three
four
five
Pets
Select Value
none
one
two
three
four
five
Guestrooms
Select Value
none
one
two
three
four
five
Guest Suite
Select Value
one bedroom
two bedroom
three bedroom
1st Language
Select Value
English
French
Arabic
Bulgarian
Catalan
Chinese
Croatian
Czech
Danish
Dutch
English
Estonian
Finnish
French
German
Greek
Hebrew
Hungarian
Icelandic
Italian
Indonesian
Japanese
Korean
Latvian
Lithuanian
Norwegian
Persian
Polish
Portuguese
Romanian
Russian
Serbian
Slovak
Slovenian
Spanish
Swedish
Turkish
2nd Language
Select Value
English
French
Arabic
Bulgarian
Catalan
Chinese
Croatian
Czech
Danish
Dutch
English
Estonian
Finnish
French
German
Greek
Hebrew
Hungarian
Icelandic
Italian
Indonesian
Japanese
Korean
Latvian
Lithuanian
Norwegian
Persian
Polish
Portuguese
Romanian
Russian
Serbian
Slovak
Slovenian
Spanish
Swedish
Turkish
Host Smoker
Select Value
Yes, smoke outside
No
Hobbies Activities
Homestay Level
Select Value
Standard
Semi-deluxe
Deluxe (with private bath)
PREFERNCES
Homestay Reasons
Prefer Gender
Select Value
Male
Female
Both
Meals Preference
Select Value
No Meals
Breakfast only
Breakfast and dinner
Three meals
Accept Smokers
Select Value
Yes, smoke outside
No
Age 15-17 years
Select Value
Yes
No
Age 18 years or above
Select Value
Yes
No
Accept Couples
Select Value
Yes
No
CHILDREN
Child (1) Name
Gender
Select Value
Male
Female
Child (1) Age
Child (2) Name
Gender
Select Value
Male
Female
Child (2) Age
Child (3) Name
Gender
Select Value
Male
Female
Child (3) Age
PETS
Pet (1) Type
Select Value
dog
cat
bird
rabit
hamister
fish
reptile
other
Pet (2) Type
Select Value
dog
cat
bird
rabit
hamister
fish
reptile
other
Pet (3) Type
Select Value
dog
cat
bird
rabit
hamister
fish
reptile
other
GUEST ROOMS
Prime Host Second Host Address Household Preferences Children Pets
Room 1 Room 2 Room 3 Location Photographs Agreements & References
ROOM ONE
Available From
Location
Select Value
ground floor
first floor
second floor
third floor
Opening Window
Select Value
Yes
No
Locking Door
Select Value
Yes
No
Bed Size
Select Value
single
twin
double
queen
king
Closet
Select Value
Yes
No
Desk & chair
Select Value
Yes
No
Bedside table
Select Value
Yes
No
TV
Select Value
In-Room
Shared
Internet
Select Value
Wireless
Cable
DSL
Computer
Dial-Up
Bathroom
Select Value
Shared
Private
Ensuite
Meals included
Select Value
No Meals
Breakfast only
Breakfast and dinner
Three meals
Remarks
Monthly Rate
Select Value
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
1025
1050
1075
1100
1125
1150
1175
1200
ROOM TWO
Available From
Location>
Select Value
ground floor
first floor
second floor
third floor
Opening Window
Select Value
Yes
No
Locking Door
Select Value
Yes
No
Bed Size
Select Value
single
twin
double
queen
king
Closet
Select Value
Yes
No
Desk & chair
Select Value
Yes
No
Bedside table
Select Value
Yes
No
TV
Select Value
In-Room
Shared
Internet
Select Value
Wireless
Cable
DSL
Computer
Dial-Up
Bathroom
Select Value
Shared
Private
Ensuite
Meals included
Select Value
No Meals
Breakfast only
Breakfast and dinner
Three meals
Remarks
Monthly Rate
Select Value
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
1025
1050
1075
1100
1125
1150
1175
1200
Prime Host Second Host Address Household Preferences Children Pets
Room 1 Room 2 Room 3 Location Photographs Agreements & References
ROOM THREE
Available From
Location
Select Value
ground floor
first floor
second floor
third floor
Opening Window
Select Value
Yes
No
Locking Door
Select Value
Yes
No
Bed Size
Select Value
single
twin
double
queen
king
Closet
Select Value
Yes
No
Desk & chair
Select Value
Yes
No
Bedside table
Select Value
Yes
No
TV
Select Value
In-Room
Shared
Internet
Select Value
Wireless
Cable
DSL
Computer
Dial-Up
Bathroom>
Select Value
Shared
Private
Ensuite
Meals included
Select Value
No Meals
Breakfast only
Breakfast and dinner
Three meals
Remarks
Monthly Rate
Select Value
300
325
350
375
400
425
450
475
500
525
550
575
600
625
650
675
700
725
750
775
800
825
850
875
900
925
950
975
1000
1025
1050
1075
1100
1125
1150
1175
1200
LOCATION
Link Map
Google Maps
Describe Neighbourhood
Bus Stop
Select Value
outside our doors
accross the street
one block away
two blocks away
three blocks away
four blocks away
five blocks away
six blocks away
further away
Other Transit
Comments
Prime Host Second Host Address Household Preferences Children Pets
Room 1 Room 2 Room 3 Location Photographs Agreements & References
PHOTOGRAPHS (only Files type *.gif, *.jpg are allowed)
Photo Host
Photo House
Photo Room (1)
Photo Room (2)
Photo Room (3)
Photo Bath
Photo Living
Photo Kitchen
Photo AddIitional (1)
Photo Additional (2)
Agreements & References
Referred By
Referral Method
Select Value
a friend
a student
a colleague
a neighbour
school or college
another agency
Google search
other search engine
other website
classified ad
directory listing
direct mail
brochure
flyer
other
References
Do you accept Host Guidelines ?
Select Value
Yes
No
Do agree to 10% agency commission Earning ?
Select Value
Yes
No
Do you accept agency homestay Rates ?
Select Value
Yes
No
If necessary, would meet and show us your home?
Select Value
Yes
No
Do you accept to submit a police report by mail Police Criminal Report ?
Select Value
Yes
No
Do you accept our Disclaimer ?
Select Value
Yes
No
