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 Please Tick

Academic Year 2012/2013 - 42 weeks

Academic Year 2012/2013 1st semester Academic Year 2012/2013 - 2nd semester 2. PERSONAL DETAILS

Contract Dates: 15/09/2012 to 06/07/2013 Contract Dates: 15/9/2012 to 19/01/2013 Note: These contract periods are for Exchange students and placement Contract Dates: 20/01/2012 to students only. 06/07/2012

UB Number (University of Bradford ID No)

5 Female

0 Home Address: Flat no. 404, Khansaheb Bldg,

Gender: Male

(please circle) (please circle)

Title: Mr Mrs Ms Dr

Surname/Family Name: Chockalingam First Name: Surya Date of Birth: 30/01/91 Will you 18 by the start of your course: Yes (Please circle) No

Rolla Road, Burdubai, Dubai, U.A.E. Post Code: 34722 .. Contact Address: Flat no. 404, Khansaheb Bldg, Rolla Road, Burdubai, Dubai, U.A.E. Post Code: 34722 Home Telephone: ......... 00971 4 3519669.. Mobile No: 00971 50 7853220..

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 5. DISABILITY/MEDICAL DETAILS Do you have a disability or medical condition Yes

E-mail Address: suryarc@live.com Correspondence will be via e-mail, please ensure your e-mail address is written clearly and accurately 4. TYPE OF STUDENT UG Foundation Year Unconditional Firm Conditional Firm UG First Year UG Returning PG First Year 6. PREFERENCES please note this cannot be guaranteed 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 Unconditional Firm Conditional Firm

No

If Yes please give further details .. Do you have mobility problems

No

Yes

Is accommodation required for a carer

No No No

Yes Yes
Yes

Do you require an adapted room

Do you require a drugs fridge

7. ACCOMMODATION PREFERENCE En-suite Room Town House

OFFICE USE ONLY: Date Received: . Finance Check: . Date Processed: