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Name:

Date of birth:
(dd/mm/yyyy)
Address:

Email Address:

1. Are you a student?
Yes I'm a student   No I'm not a Student - please go to question 4

2. Where are you studying?

3. What are you studying?

4. Are you working?
Yes I'm working   No I'm not working - please go to question 7

5. What do you do?

6. Do you use english in your job?

7. What study of English have you done?

8. How well do you speak English? (choose those that apply to you)
I can introduce myself and greet people
I can talk about me
I can understand basic English when spoken to
I can have a simple conversation
I can have a complex conversation
I am quite fluent
I am a fluent English speaker

10 .Which of the Live and Learn New Zealand packages do you want to do?
Teaching Internship New Zealand (choose from; primary or high school & rural or urban):
Primary school High school Rural school Urban school

Study New Zealand (choose from; english school, high school or university):
English School High School University

Work Experience New Zealand (choose from; farm or other):
Farm
Other types of work experience

11. When do you want to come to New Zealand?

12. How long do you want to stay?

13. Why do you want to come to New Zealand?

14. What do you know about New Zealand already?

15. What do you hope to gain from your New Zealand experience?

16. We will try and place you in a home-stay close to activities that interest you.
What do you like to do in your free time?

Swimming Fishing Tramping Going dancing Going to the movies Skiing Playing Sport Going to the gym Going to cafes Socialising

17. Which to you like the most?
Mountains The sea Busy city Forests Farmland

18. Do you want a city experience or country experience? Why?

19. What are your strengths?

20. What are your weaknesses?

Thank you!
We will use this information and formulate your individual Live and Learn New Zealand experience. We will reply in e-mail form within seven working days of receiving your application.

© 01/2007 Live and Learn New Zealand Limited :: Jenny Chapman :: Postal Address: 837 Mangaehu Road, RD22, Stratford, NEW ZEALAND :: Tel: +64 6 762 3555