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PONTIFICIA UNIVERSIDAD CATÓLICA MADRE Y MAESTRA
International Students Office
Santiago, Dominican Republic


HOUSING FORM
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International Students Office


Please answer this questionnaire carefully. We will use the information you provide in your answers to arrange for your accommodations in Santiago, Dominican Republic. Although we cannot guarantee that your housing placement will correspond exactly to your request, having detailed and complete information about your references increases our chances of meeting your needs that should be included in this questionnaire.

International program you belong to *   

CANDIDATE’S LEGAL NAME
First Name *: Middle Name:  Last Name *: Preferred name/nickname:
   

GENERAL INFORMATION
Date of Birth (mm/dd/yyyy) *:   City of Birth *:  
Country of Citizenship *   Country of Legal Residence *:  
Passport Number *:   Passport Expiration Date *  
Gender *
 
(mm/dd/yyyy)

ADDRESS AND CONTACT NUMBERS
Street/P.O. Box *:  
Zip/Postal Code *:   City & State/Province *:  
Country *   Telephone:
Mobile Phone: Fax:
Email Address *:    
 
INFORMATION ABOUT PARENT
Mother First Name:  Last Name: Business and/or Mobile Phone:
Email address:
Father First Name:  Last Name: Business and/or Mobile Phone:
Email address:

CONTACT DETAILS OF ANY NATURAL PARENT WITH WHOM I DO NOT LIVE
First Name: Last Name: Business and/or Mobile Phone:
Street/P.O. Box:
 Zip Postal Code:
City & State /Province:
Email Address:

EMERGENCY CONTACT
If you’re parents cannot be reached, please indicate someone whom we can contact:
First Name: Last Name: Relationship:
Telephone Numbers:  Home: Mobile:
Business:
 
STUDIES & PROFESIONAL LIFE
University that you attend:
Major:  Minor: 
What other academic interests do you have?
What are your professional plans?

TRAVELS
Have you ever lived in another country? *
 
If you checked Yes, please specify:
Country Time Reason  Type of Accommodations
Have you ever been to Dominican Republic? *
 
If you checked Yes, please specify:
Where: When:  Why:  Type of Accommodations

HOST SITUATION
Which type of host family would you prefer? *
 

MEDICAL REQUIREMENTS AND HEALTH RESTRICTIONS
Do you have physical restrictions, impairments or allergies that will limit placement options or participation in everyday family and/or school activities? *
 
If Yes, please explain:
Please check the appropriate boxes if you CANNOT live with:
Cats Dogs Other Pets
If you checked Other Pets, please explain: 
If you checked that you CANNOT live with a pet, please indicate why:

DIETARY REQUIREMENTS
Do you have dietary restrictions, including for medical, religious or self-imposed reasons? *
 
If Yes, please explain:
If you are a vegetarian, are you willing to eat:

RELIGION
What is your religious affiliation, if any? (Optional)
How often do you participate in structured religious services?
Bearing in mind that it is likely your host family will have a different religious affiliation, how strongly do you feel about having access to structured religious services of your own faith? *
 

SMOKING
Do you smoke cigarettes? *
 
In our culture it is more difficult to find placements for cigarette smokers. Given this, smokers should please choose one of the following:

ALCOHOLIC BEVERAGES
Do you drink alcoholic beverages? *
 
Do you mind living in an environment where a host drinks these beverages? *
 
Comments:


INTEREST AND ACTIVITIES
Identify your major interests and activities, and indicate how often do you pursue them:

LANGUAGES
Native Language *  
Language profiency (for languages other than your native language)
Language: Years studied: Speaking ability:
Language: Years studied: Speaking ability:
Language: Years studied: Speaking ability:
Language: Years studied: Speaking ability:

CANDIDATES PERSONALITY
Please check all that apply:







If you play an instrument or have specific artistic skills, please specify:

If there are any issues such as religion, sexual orientation, civil status, disability, etc, that are important to you, please share the details with us. All information is confidential and personal. Based on this, we will be able to place you in a comfortable home stay.

ABOUT YOU
Describe yourself briefly in the followinglines. You may talk about your likes, dislikes, hobbies, background, skills etc. and also give us more details about your dietary, allergic, smoking, etc. conditions if it applies. Also talk about the expectations from your exchange experience in Dominican Republic. This can also be an introduction of yourself to the family that will be hosting you.

PHOTO
Please send a picture of yourself *  



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