Long Term Accommodation Application Form

Applicant Contact Details
Family Name:
Given Name(s)
Preferred Name:
Title:
Gender: Male Female
Date of Birth : DD/MM/YYYY
Contact Home Address
Address 1:
Address 2:
City:
Province / State:
Postal Code / ZIP :
Country:
Telephone:
Mobile:
Email:
Alternate Email:
Special Requirements
Please answer the following questions in order for Education City to provide you with the most appropriate accommodation to suit your needs. All information provided will be treated as confidential.
Preferred Accomodation 1:
Preferred Accomodation 2:
Please select your preferred share accommodation option:
Male only Female only Male / Female
Course Details
Education Provider:
USQ Bremer TAFE ACC UIL STS None
Other (Please Specify)
Course /
Programme Name
Length of Stay
Duration:
Arrival Date: (DD/MM/YYYY)
Departure Date: (DD/MM/YYYY)
Payment of accounts
Please indicate who will be responsible for the payment of accounts (e.g. Own Income, Savings, Parent / Guardian, Other)
Own Income Parent / Guardian
Other (Please Specify)
Name of Contact Person
Family Name:
Given Name(s):
Preferred Name:
Title:
Address1:
Address 2:
City:
Province / State:
Postal Code / ZIP :
Country:
Telephone:
Mobile:
Email:
Additional Information
Do you have any other requirements or information to assist us with your application?
Medical:
Disability:
Other:

How did you hear about the Education City Residential Village?
I certify that the information contained in this application is complete and accurate
 I agree for my Personal Information to be given to USQ Springfield for the Setup of Internet Quotes
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