Surname/ Family Name:

First and Other Names:

Male/ Female: Male Female

Date of Birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990

Please note that there are age restrictions in use

Country of Origin:

Native Language

Home Address:

Current Address:

Telephone Number:

Mobile Telephone Number:

E-mail Address:

Place of Study in Birmingham:


Course of study

Course Start Date

Course End Date

Date from which accomodation is required

Do you need a single or double room? Single Room Double Room

If you need a double room, please give the name of your spouse

Do you smoke? Yes No

Do you have any special needs?


Where did you hear about Wesley International House?


Name and address of person who will give you a reference: