Applicant Information (Required) Name: Address: City: State: WA Zip (Postal) Code: Home Phone: E-mail: Family Information (Required) 1. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests:       2. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests:       3. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests:       4. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests:       5. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests:       6. Name:   Gender: Male Female   Date of birth: (MM/DD/YYYY)   Relation:   Occupation:   Living with you?: Yes No   Interests: Pet Information Do you have any pets in your house? Dog Cat Other Heads of Household Employment Information (Required) 1. Name:   Company Name:   Occupation::   Address:   Phone:   Workdays: Mon Tue Wed Thu Fri Sat Sun   Typical Work Hours: From: To:       2. Name:   Company Name:   Occupation::   Address:   Phone:   Workdays: Mon Tue Wed Thu Fri Sat Sun   Typical Work Hours: From: To: Please write a note for your future student. Home Information (Required) Which type of home do you live in? House Apartment Condominium Other How many bedrooms are there in your home? 1 2 3 4 5 6 More Please select the bathroom arrangement for students. Private Share Please select items available in the student's room. Bed Desk Lamp Chest or Drawer Closet Phone Jack Cable connection for TV TV Please select Internet connection Dial-up DSL Cable DSL or Cable and Wireless Household Rules (Required) Is smoking allowed in the house? Yes No Are there special dietary restrictions or practices in your family? Yes No If yes, please explain. Cultural Information (Required) Are any languages other than English spoken or studied in your family? How many students have you hosted and for how long? Transportation (Required) How long does it take to walk to the nearest bus stop from your house? Which bus would the student need to take? Transfer required? Yes No Commute Time? *Please call Metrofs 24 hour Rider Information at #206-553-3000 or go to Metrofs web site. Other House Rules If you have any house rules, please explain. e.g. No alcohol inside house. No incoming calls after 10:00pm, etc. Emergency Contact (Required) Name: Address: Relation: Day Phone: Evening Phone: Personal References (Required) 1. Name:   Relation:   Phone:       2. Name:   Relation:   Phone: Background Check Consent Form (Required) I understand the importance of placing students in safe environments. I give ICC and its staff permission to conduct a criminal background check on me. Self First Name:   Middle Name:   Last Name:   Birth Date: (MM/DD/YYYY)       Spouse(Partner) First Name:   Middle Name:   Last Name:   Birth Date: (MM/DD/YYYY)