A&E Quality Education Services Centre 14-888 West 16th Street North Vancouver, BC V7P 1R3 Canada Phone: 1-604-725-4725 Fax: 1-604-929-6644 E-mail: aeqesc@telus.net Home-stay Information First Name Last Name Gender Male Female Your e-mail Your Address: Street City Province/ StatePostal code Country Phone: Area code Information about your Home-stay: How many rooms available 1 2 3 4 5 6 How many People living there 1 2 3 4 5 6 How many Students do you like to have 1 2 3 4 5 6 Special diet: Regular North American vegitarian South American Asian Indian Europian Iranian Mix Other Do you have pets? Please specify: Something about yourself: Please give us more information about your Home-stay. For example, if you have any special prefrence like to govern in your place...: (optional) When your Home-stay is available? Please give us your feed back: