APPLICATION FOR RESIDENCE ACADEMIC SESSION 2011/12

COMPLETE THIS FORM IMMEDIATELY Use BLOCK CAPITALS throughout. 1. Title (Mr/Mrs etc.) 2. Surname/Family Name 3. First/Given/Other Names

FOR OFFICE USE

4. UCAS Personal ID Number (Undergraduates only)

5. Sex () Male Female

6. Marital Status () Single Married Civil Partnership

7. Date of Birth Day Month Year 8. Nationality

9. Admissions/Application Number (Graduate or Affiliate Students)

10. Programme (e.g. BSc)

11. Subject (e.g. Neuroscience)

12. Department (e.g. History)

13. Previous University

14. Permanent Home Address FOR OFFICE USE Year Postcode/Zip Email 15. Correspondence Address (if different from above) Tel No. (with code) Fax No. (with code) Valid from: Until: Special Ack. Priority

Postcode/Zip Email

Tel No. (with code) Fax No. (with code)

16. Name of Parent/Guardian/Next of Kin, and Address (if different from above)

Postcode/Zip Tel No. (with code) Relationship 17. In 2011/2012 I will be a () Full-time or student on a () Exchange or 18. I have previously lived within the M25 motorway (within Greater London) when a university student () If yes, please state full postal address and dates Yes No JYA (Junior Year Abroad) Part-time Undergraduate or Graduate and I will be in the () 1st or 2nd or 3rd or 4th or 5th year Fax No. (with code)

Recent passport size photograph of yourself MUST be stapled here.

Recent passport size photograph MUST be stapled here. (This second photograph should be of YOU if you are applying for SINGLE person accommodation or of your PARTNER if you are applying for COUPLED accommodation). Applications will NOT be considered unless accompanied by TWO photographs.

19. Personal activities and interests My main interests are:

20. Please give details of any disability, illness or other special needs and attach supporting documentation

21. EITHER A. For Applicants Requiring SINGLE PERSON Accommodation. Please note all residences are non-smoking. Do you want to share a room (single beds)? () Will you want to share a room if no single rooms are available? () Yes Yes No No Full name and department of another applicant with whom you are prepared to share (if any):

Please note: We will consider your preference, but may not be able to meet it. Applicants aged under 19 years old are likely to be offered shared rooms if placed in self-catering accommodation. OR B. For Applicants Requiring COUPLED Accommodation (married or in a civil partnership). Please note all residences are non-smoking. Please state full name of your partner: Please indicate any programme of study or employment in which your partner intends to engage: Please indicate number of children, their sex and ages, for whom accommodation is also required: (9/H/I/J/K)

22. Dates Accommodation Required If Not For The Entire Session (24 September 2011 23 June 2012) (See www.ucl.ac.uk/accom-apply) From 23. For Prospective Undergraduates and Graduates Please indicate the order of preference you may have for the type of accommodation required by placing 1 (first), 2 (second), 3 (third), etc. in the relevant boxes below. We cannot guarantee to meet your preference. Order of Choice Order of Choice UCL Halls of Residence (meals provided) Intercollegiate Hall (meals provided) UCL Student Houses (self-catered) No preference To

For Intercollegiate Halls only please name your 1st and 2nd preferences. 1st preference 24. For all Applicants Please indicate the single most important factor to you in your preference for accommodation with a () in only one of the boxes. Catered Hall En suite bath Low cost Other (Please state) Please indicate the MAXIMUM weekly rent you are prepared to pay for your preferred type of accommodation: 25. For All Applicants (This is not used for selection purposes but to assist in the preparation of Electoral Registration Lists.) If you are a citizen of the United Kingdom, Eire, or the British Commonwealth and will be eligible to vote in British Elections subsequent to 1 December 2011 please place a () in the box below. (Failure to do so may mean that you will not be registered to vote if you obtain a place in a UCL or University residence.) I will be eligible to vote in British elections If you are a citizen of an EU state other than the United Kingdom or Eire and will be eligible to vote in EU Elections subsequent to 1 December 2011 please place a () in the box below. (Failure to do so may mean that you will not be registered to vote if you obtain a place in a UCL or University residence.) I will be eligible to vote in EU elections Please place a () in the box if you want your details to appear in the edited list which can be purchased from Electoral Services offices by anyone for any purpose. per week Self-catered House Computer Points Car Parking Single Room Shared Flat With PG/Mature Students Proximity to UCL 2nd preference

Declaration: I understand that omissions or falsifications of this application form make it invalid and that final acceptance will depend on my agreeing to abide by the Rules and Regulations of the Hall or House. I accept that the prompt payment of residence fees within the period set out in the regulations is a condition of residence.

Signed

Date

It is imperative that only one form is completed for ALL UCL and University residences. The completed application form should be returned immediately to: UCL Student Residences, University College London, 117 Gower Street, London WC1E 6AP . PLEASE NOTE that it is your responsibility to ensure the safe arrival of this application form. All forms received will be acknowledged. Please contact UCL Student Residences if you do not receive an acknowledgement of receipt of this application within four weeks of returning it to UCL Student Residences. DATA PROTECTION ACT UCL Student Residences will use the information given on this form for administrative purposes only. The information will be destroyed in accordance with the UCL Data Protection Policy.