A1 Level 1 : Learning activity 3 : Stage 31

MOVING TO A NEW PLACE Home Tearch application

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Please write the first or main applicant’s surname here Rojas Cuellar
Important: Please make sure you read all the information presented in this document carefully before
you complete this form.

A. Your details
First name(s) Leidy Viviana

Give any other name(s)

you were previously known by

Date of birth 26/09/1993

For example 06/12/1968

RACE 8 # 4 – 61
Current address

+ 57
Postcode

Contact/correspondence STREEP 8 # 5 - 2
or safe address (if different
from above)

Contact telephone 3102525101

numbers(s)

Ladii.21@hotmail.com
Email address
Servicio Nacional de Aprendizaje - SENA. Reservados todos los derechos 2013.
 A1 Level 1 : Learning activity 3 : Stage 1

Do you experience difficulties Yes X No

with reading or writing?

What´s your gender? Male Female X

What is your religion? Buddhist Hindu

Prefer not to say X
Christian Jewish

Muslim Sikh None Other

(please specify)

B. Employment information
If you are working, please tell us: Yes No X

What do you do? STUDENT

C. Your family or household

We need to know if other people will be moving with you. This will help us to know what type of home
you will need. Please give their details below.

1st 2nd 3rd

ROJAS CUELLAR ROJAS
Last name
MARTIN STELLA STEFFANIA
First name
03/10/1968 14/09/1968 27/01/2003
Date of birth
MALE FEMALE FEMALE
Gender
FATHER MOTHER SISTER
Relationship
to you (wife,
son, etc.)

Servicio Nacional de Aprendizaje - SENA. Reservados todos los derechos 2013.

 A1 Level 1 : Learning activity 3 : Stage 1

D. Your present accommodation/circumstances

Tick the box against the property type in which you live or best describes your circumstances.

House Trailer Hostal

X

Flat/apartment condominium Hotel

Bungalow Cottage Terraced house

Detached house Semi-detached house No fixed address

E. Your house preferences

State your house preferences describing all the characteristics you want your new home to have.

House type (apartment, cottage, etc.) HOUSE

Number of rooms SIX ROOMS

Number of bathrooms TREE BATHROOMS

Which floor (if located in a building) TEN

WATER, GAS, ELECTRICITY, INTERNET

Public utilities (gas, water, etc.)

Location LOS ANGELES CALIFORNIA

Price

Servicio Nacional de Aprendizaje - SENA. Reservados todos los derechos 2013.

 A1 Level 1 : Learning activity 3 : Stage 1

F. Special requirements
Write a more detailed description of the kind of house you want to have.

G. Applicant´s signature
Name

Date

Servicio Nacional de Aprendizaje - SENA. Reservados todos los derechos 2013.