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 *
Middle Name
Last Name *
Gender *
Date of Birth
Phone Number *
Email address *
Home Address *
Street Address Line 1
Street Address Line 2
City *
Postal Code *
Country of Passport *
Your name as it appears on your passport *
(for our records--not to be shared)
Passport Number *
(for SSCA records only--not to be shared)
Passport Expiration date *
(mm/dd/yyyy) Passport must be valid a minimum of 6 months after the date of departure.
Primary vocation (for match) *
Secondary vocation (for match) *
Other vocation/interests
(sports, hobbies, etc.)
Do you have pet or food allergies/restrictions? *
If yes, please describe:
Your Available Hosting Window :
Your Available Travel Window:
Skype name
(to be shared with your match, once found)
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)
English Kentei Grade (1, pre-1, 2, pre-2, others)
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)
Submit your Application
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