Sunnyvale-Iizuka Adult Exchange Program Application
Thank you for your interest in the Sunnyvale-Iizuka Adult Exchange Program.

**Please be sure to complete this application before submitting. Partially completed applications will not be saved.

Applications are accepted on a rolling basis and after submission, your application will be valid for nine months. Please notify the SSCA should any circumstances change. SSCA requires a minimum of 6 weeks to find a match. When a match is found, SSCA will send a notification with match details and also if a match is not available.

Personal Information
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Gender *
Required
Date of Birth
(mm/dd/yyyy)
Your answer
Phone Number *
Your answer
Email address *
Your answer
Home Address *
Street Address Line 1
Your answer
Street Address Line 2
Your answer
City *
Your answer
Postal Code *
Your answer
Country of Passport *
Your answer
Your name as it appears on your passport *
(for our records--not to be shared)
Your answer
Passport Number *
(for SSCA records only--not to be shared)
Your answer
Passport Expiration date *
(mm/dd/yyyy) Passport must be valid a minimum of 6 months after the date of departure.
Your answer
Primary vocation (for match) *
Your answer
Secondary vocation (for match) *
Your answer
Other vocation/interests
(sports, hobbies, etc.)
Your answer
Do you have pet or food allergies/restrictions? *
Required
If yes, please describe:
Your answer
Your Available Hosting Window :
(mm/dd/yyyy-mm/dd/yyyy)
Your answer
Your Available Travel Window:
(mm/dd/yyyy-mm/dd/yyyy)
Your answer
Skype name
(to be shared with your match, once found)
Your answer
This section is for Japan applicants.
If you are a US applicant, you can skip this section and go on to submit your application.
TOEFL Score or TOEIC Score (list)
Your answer
English Kentei Grade (1, pre-1, 2, pre-2, others)
Your answer
If you do not have a Kentei Grade, TOEFL or TOEIC scores, please self-rate your English level on a scale of 1-10.
(scale: 1-beginner, 10-fluent)
Your answer
Submit your Application
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