ACCOMMODATION REQUEST FORM

I wish to stay in Malta and enquire about the possibilities to stay with a host family:

CONTACT HOST FAMILY LOOZA
Title * *	MrMsMrs
Name * *
Surname * *
Gender * *	malefemale
Nationality * *
Travel Partner's Title	MsMrMrs
Travel Partner's Name
Travel Partner's Surname
Gender	maleFemale
Travel Partner's Nationality
In case of Emmergency contact person *
Emmergency contact tel number *
Do you have any medical conditions or allergies *
Your Date of Birth * *
Reason for Visiting Malta * *
Your address / Street * *
City * *
Zip / Post code *
Country * *
Your email address * *	please ensure you fill in your address correctly
Your Contact mobile phone Nr. * *
Occupation * *
Arriving on (date): * *
Leaving on (date): * *
Board Basis *	No Meals - Self cateringBed and BreakfastBreakfast and DinnerBreakfast, Packed-Lunch & Dinner
Room Type *	Twin roomsingle roomRoom shared with another person
would you like internet connection?	Yes   No
Any questions you have:
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