Accommodation

Please complete all sections if you want us to arrange your accommodation. Otherwise only complete sections C and D.

Section A:

Personal Details

Name: __Telushkin __ Dmitry ________ Date of Birth: __ 28.04.1993________

Mobile: ___________ 8-916-299-03-01__________ Email: [e-mail]

Gender: Male Female Nationality: __ Russian _________

Section B:

Accommodation

Would you like us to find you accommodation? Yes No

If yes, what type of accommodation would you like?

Host family single Shared student accommodation (own bedroom)

Host family (shared bedroom)

Would prefer to share with: ________________________

Dates accommodation required (if possible you should arrive on a Sunday and leave on a Saturday)

No. of weeks 2,5

From 05 07 12 To 23 07 12

Day Month Year Day Month Year

Do you smoke? Yes No

(It is sometimes difficult to find suitable smoking accommodation)

Would you live with a family who smoke? Yes No

Would you live in a home with children? Yes No

Would you live in a home with a pet? Yes No

If you have a special diet or other requirements (Please specify)

Section C:

Arrival Information:

Would you like to be met at point of arrival in the UK? Yes No

(NB Students will be charged for this service).

If ‘yes’ please specify:

Arrival Airport: Heathrow Departure Airport:

Gatwick

Stansted Airline:

City Airport

Flight Number: Time of Arrival: AM/PM

Section D:

Health and Safety:

Give details of any medical condition or other information the host family and/or college should be aware of:

I am healthy.

Equal Opportunities:

We are required to ask this question in order to assess the extent of representation of ethnic groups in relation to our Equal Opportunities policy. Your answer does not affect the outcome of your application.

How would you describe your ethnic background? (Please tick)

Asian or Asian British – Bangladeshi Mixed – White and Asian

Asian or Asian British – Indian Mixed – White and Black African

Asian or Asian British – Pakistani Mixed – White and Black Caribbean

Asian or Asian British - any other Asian background Mixed – any other Mixed background

Black or Black British – African White - British

Black or Black British – Caribbean White - Irish

Black or Black British - any other Black background White – any other White background

Chinese Any other

Prefer not to say/Not known

Thank You

Completed forms should be returned by post to:

Дата добавления: 2015-10-28