application form (PDF)

Utp Mesra GO
Universiti Teknologi Petronas
Bandar Seri Iskandar
31750, Tronoh
Perak Darul Ridzuan
“One family one UTP”
1. Application information :
Categories
1. Staff
2. Local
Full Name

Gender
Male
Date of birth

Student
International

Religion
Female
Age

I/C or Passport no

Staff or student ID

Status
Single

Do you have children?
Yes

Married

If yes, how many?
Mailing address

Email address

Hand phone number

Home phone number

Occupation

Department or course

Year of study

No

Next of Kin

Contact number

3. Personal background :

Do you have any dietary restriction? (For guest only)
Yes
No
If yes, please explain (e.g., vegetarian, food allergies, religious reason like fasting) :

Are you currently on any medication or have any health problem? (For guest only)
Yes
No
If yes, please explain (e.g., asthma, allergies, handicaps) :

Are you a smoker?
Yes

No

Do you drink alcohol?
Yes

No

If yes, I understand I must smoke outside.
Do you want to live in a home with : (For guest only)
Young children (0 to 5 years): Children (6 to 12 years ):
Teenagers:
Yes
No
Yes
No
Yes
No
Older people:
Family with no children:
Yes
No
Yes
No
What animals or pets would you not accept in your homestay house? (For guest only)

Would you be willing to share a room with another student or family member?
Yes
No
(You may be asked to share a room with a host family or another student)
HOBBIES, INTERESTS & PREFERENCES :- please pick what applies
Soccer
Computers
Dancing
Water sports
Cycling
Camping
Roller Blading
Basketball
Reading
Bowling
Volleyball
Fine Arts
Material arts
Football
Video games
Car Racing
Baseball
Swimming
Movies
Others :
Type of music :

Instrumental played :

PERSONAL CHARACTERISTICS :- please pick what applies
Quiet
Modest
Humorous
Studios
Serious
Independent
Nervous
Talkative
Shy
Active
Energetic
Curious
Social
Patient
Outgoing
Please tell us any other information or your special requests :

Cautious
Calm
Tidy
Others :

4. Language proficiency :
Languages
Fluent

Proficiency
Moderate

Basic

Bahasa Melayu
English
Other Languages:

5. Notes :
 We will do our best to match you with your homestay family. However, we
cannot guarantee to meet all of you requests.
 Please fill all the forms to make us easier to find your match for this homestay
program. You will automatically eliminate for any incomplete form.
Contacts:

012-2531389(Emira)
016-3631439(Tanzeev)

Signature

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