Partners in Cross-Cultural Learning - Community Partner Information Form

Personal Information
First Name:
Last Name:


Age Range:


Marital Status:
Other Houshold Members' Age and Gender:
Do you have pets? If yes, please state the number and type of animal:
Does anyone in your household smoke cigarettes?


Contact Information
Home Address:
Zip/Postal Code:
Home Phone Number with area code:
Alternative Phone Number with area code:  

Best time to reach you:


Email Address (that you check regularly):
International Experience
What is the extent of your international experience? (Examples: travel, student host, work abroad, etc.)  
Country (ies) of special interest:
What foreign languages do you speak (if any)?  
Professional and Recreational Interests
What is your occupation?  
What are your professional interests?
What hobbies or activities do you enjoy?
Please list any memberships or affiliations you have (e.g. Kiwanis, P.T.A., professional organizations, etc.)
What do you hope to gain from your PICL experience?
Preferred Student Partner Attributes
Region/Country of Origin 1st choice:  
2nd choice:  
No Preference


Language Ability:
Do you object being paired with a student who is a smoker?  Yes    No    No Preference
Please list any additional partner attributes that might be important to you: (religion, smoking, marital status, etc.)
If we cannot meet all of your preferences, will you accept being paired with another student?
Are you interested in being paired with more than one student at this time?

Thank you for applying!! We will contact you soon.

Questions, Comments, Suggestions?

If you have any questions about the Partners in Cross-Cultural Learning Program at SUNY-Plattsburgh, please contact the PICL Coordinator:

Carolina Dela Rosa
Global Education Office

State University of New York at Plattsburgh
Kehoe Administration Building, Room 210
101 Broad Street
Plattsburgh, New York 12901 USA

Phone: (518) 564-3287
Fax: (518) 564-3292