Last Name:         First Name: 

Home Address: 

                        City:    State:    Zip: 

Home Telephone:  (Area Code)

ETSU Department:    ETSU Telephone:   
Email:    ETSU Box: 

Relationship to ETSU:  Please Select: Faculty Staff/Administrative Student Friend of the University

I    Please select Have a Have no preference as to the country the student is from.  If so, I prefer the student be from country/continent.

Gender preference   Please Select Male Female Either   Student Status:         Please Select Undergraduate Graduate Either

Would you prefer a student majoring in a specific field of study?  No Yes  
IF YES, indicate field: 

Most of our international students will want to practice their English.  However, do you have facility with any languages?  No Yes   IF YES, please provide the language and your assessment of your level of verbal ability:

Countries you have visited/have an affiliation with, if any:

Would you be able to house a student for a short period of time (2-5 days) if necessary?  Yes No   If YES, how many nights could you provide accommodations? 

Please let us know if you would NOT be able to accommodate students' dietary needs, e.g., vegetarian, no pork, no beef, etc.  Please Select Can Accommodate Cannot Accommodate

Do you have any pets?    Please Select Yes No   If yes, what kind?

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