AIS Residences Form

Personal DetailsPreferred title *

MrMrsMissMsDrOther

Gender *

MaleFemale

First name *

Last name *

Date of birth *

Your email *

Expected arrival date to ASC Residences

Expected departure date

Phone / Mobile

Address *

City *

Postcode *

State *

ACTNSWVICQLDWASANTTASOverseas

Country *

Do you have a difference mailing address? *

YesNo

Mailing address (if different from above)

City

Postcode

State *

ACTNSWVICQLDWASANTTASOverseas

Country

Are you an international student? *

YesNo

Next of KinName *

Address *

City *

Postcode *

State *

ACTNSWVICQLDWASANTTASOverseas

Phone/Mobile *

Relationship *

Email of Next of kin *

Personal InformationMedical conditions

List of any major illness or surgery occurring in the last 12 months

List any medication required to be taken on an ongoing basis

Fee OptionsPlease choose fee options *

Option 1: Full year paymentOption 2: One semester payment

Method of payment *

Credit cardElectronic Fund Transfer

Credit Card Details (if paying by credit card)Name of Credit Card Holder

Credit Card Number

Credit Card Expiry (mm/yy)

Educational Enrolment DetailsEducational Institution joining *

Course name *

Level of study *

Student ID No. *

Character ReferenceName of referee *

Email of referee *

Address

City

Postcode

State *

ACTNSWVICQLDWASANTTASOverseas

Character reference instructions

Please provide a written statement from a personal referee to support this applicatiuon. Please limit the statement to an A4 page. Maximum file size is 2MB. Accepted file types are doc, docx, pdf and jpg

Character reference in support of your application *

Additional DocumentationCopy of identification of passport

Photo ID in addition to passport (driver's license is acceptable) *

Personal DeclarationPrivacy statement *

• Yes - I consent to the ASC holding any personal information I have provided.

Please check that you have answered all required questions, and that your attachments (if any) are showing, especially if you have received form errors.