Unilodge Agency Priority Application Form

AGENCY PRIORITY APPLICATION FORM * Compulsory field. Please print clearly. This Priority Booking Form must be completed and submitted as outlined in your UniLodge Agency Agreement to receive priority. The room cannot be held for the student until the application has been approved and 4 weeks rent (cleared funds) has been paid to UniLodge. The standard cancellation fee of 4 weeks rent will apply to cancellations made less than 1 month prior to the start date of the lease. *UniLodge Property Name Agency Details * Agency Name * Contact Email Address Student Details *First Name *Family Name *Gender  Female  Male *Date of Birth *Will you be under 18 on arrival?  Yes  No *Proposed Arrival Date *Proposed Departure Date Accommodation Preferences* (Preferences cannot be guaranteed) List in preference order 1, 2 & 3 List as per 1. 2. 3. Payment Plan*  Instalments (monthly )  Up front payment Other requests - If you have any special requests please list them below – requests cannot be guaranteed. Personal Details Nationality* Parent/Guardian Name (if under 18)* Home Country Address* Home No. Fax No. Mobile No.* Email* Medical Conditions (incl. disabilities) Emergency Contact Details Name* Relationship to you* Home No.* Mobile No.* Australian Residents* Aust. Drivers License No.* State* Expiry Date* International Residents* Passport No.* Expiry Date* Visa No.* Expiry Date* Education Information (e.g. university, college, school etc) Name of Education Institution* Start Date* Name of Course* End Date* Post Graduate/Undergraduate* Student Number* Authorisation Agent Signature* Date* Agent Name* Office Use Only Room Type Room Rate Other