Syracuse, New York, U.S.A. Homestay

Please print out this form,write in all information and then mail or fax it to A in J FORTUNE

PERSONAL INFORMATION

Name: First________________________________________________ Last_____________________________________________________

Sex: Female______Male____ Date of Birth: Month_____Day____ Year_______

Address:________________________________________________________________________________________________________________

City/Town(町)___________________ Prefecture（県）___________________Country____________________

HOMESTAY INFORMATION

I would like the: ____ 8 day course ___ 15 day course

I would like the Syracuse,New York, USA, homestay starting from (month/day/year):

FROM:_________________________________________ TO: ________________________________________

Do you have any allergies? Yes______________ No______________ If yes,______________________________________

Indicate any special dietary needs or medical concerns:______________________________________________

Would you like pick-up at the Syracuse airport? ___Yes ____No

If yes, Airline______ Arrival Date: Month______Day______Year_____ Arrival Time:_________________

Airline:________________________________________ Flight Number:__________________