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University of Bradford Student Accommodation Application
Note: Please use black ink and write as clearly as possible
using capital letters.
1. Please select accommodation period
PleaseTick
Academic Year2012/2013 - 42 weeks
Contract Dates: 15/09/2012 to06/07/2013
Academic Year 2012/2013 1st
semesterContract Dates: 15/9/2012 to 19/01/2013 Note: These
contract
periods are for Exchangestudents and placementstudents only.
Academic Year 2012/2013 - 2nd
semesterContract Dates: 20/01/2012 to06/07/2012
2. PERSONAL DETAILSUB Number (University of Bradford ID No)
1 2 0 1 5 0 4 0
Gender: Male Female (please circle)
Title: Mr Mrs Ms Dr (please circle)
Surname/Family Name: Chockalingam
First Name: Surya
Date of Birth: 30/01/91
Will you 18 by the start of your course:Yes No(Please
circle)
Home Address: Flat no. 404, Khansaheb Bldg,Rolla Road, Burdubai,
Dubai,U.A.E.Post Code: 34722 ..Contact Address: Flat no. 404,
KhansahebBldg, Rolla Road, Burdubai, Dubai,U.A.E.Post Code: 34722
Home Telephone: ......... 00971 4 3519669..Mobile No: 00971 50
7853220..
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Nationality: Indian ..3. COURSE DETAILS
School/Dept of Study: School of Engineering,Design and
Technology
Course Title: MSc Medical Engineering..
Student Status: Home/EU
International
Other
E-mail Address: [email protected] will be via
e-mail, please ensureyour e-mail address is written clearly
andaccurately
4. TYPE OF STUDENT
UG Foundation Year Unconditional FirmConditional Firm
UG First Year Unconditional FirmConditional Firm
UG Returning
PG First Year
5. DISABILITY/MEDICAL DETAILS
Do you have a disability or medical condition Yes
No
If Yes please give further details..
Do you have mobility problems Yes
No
6. PREFERENCES please note this cannot beguaranteed
Do you prefer to be in/with :
Male Only Area
Female Only Area
Mixed Male & Female
Mature UG Student Area
Students on a similar course
No Prefernce
mailto:[email protected]:[email protected]
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Is accommodation required for a carer Yes
No
Do you require an adapted room Yes
No
Do you require a drugs fridge Yes
No7. ACCOMMODATION PREFERENCEEn-suite Room Town House
OFFICE USE ONLY:Date Received:.Finance Check:.Date
Processed:
