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UniLodge on Flinders Application Form

unilodge.flinders@unilodge.com.au

First Name:

Family Name:

Gender:

Male Female

Date of Birth :

Will you be under 18 on arrival?

Y N

Proposed Arrival Date:

Proposed Departure Date:

Accommodation Preferences

(You must list at least 3 bedroom type preferences 1 to 3 with "1" being your first preference)

Studio	One Bedroom Apt
Standard	Standard
Superior	Superior
Deluxe

Two Bedroom	Prefered Position / Level
Standard	Low Level High Level
Superior

Payment Plan:

Instalments Up Front Payment

Nationality:

Parent / Guardian Name:

Home Country Address:

Telephone No:

Fax No:

Mobile No:

Email:

Emergency Contact Name:

Emergency Number:

Medical Conditions (Incl. disabilities):

Passport Number:

Expiry Date:

Australian Visa Number:

Expiry Date:

Name of Course:

Name of Institution:

Start Date:

End Date:

Did you hear about UniLodge through an education agent:

Yes No

If yes, please indicate the agency name:

Agent's City Location:

Are you applying to UniLodge through an/this education agent?:

Yes No

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Enter the characters as they are shown in the box below.

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Contact details
UniLodge on Flinders
238 Flinders St
Melbourne
VIC 3000

Tel: 61 3 9224 1500
Fax: 61 3 9224 1530

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What our students say...

Great place to stay with marvellous friendly staff......
Iskandar Isehak – QUT

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