89 Crwys Road
Cathays
Cardiff
CF24 4NF
Tel; 029 2023 111
APPLICATION FOR ACCOMODATION
PLEASE WRITE IN BLOCK CAPITALS
SURNAME OTHER NAMES SEX
HOME ADDRESS TELEPHONE NUMBER
(inc postcode) (inc STD Code)
MOBILE NUMBER
DATE OF BIRTH NATIONALITY RELIGION
MARITAL STATUS NO. OF CHILDREN
NEXT OF KIN
NAME RELATIONSHIP TO YOU
HOME
ADDRESS TELEPHONE MOBILE
NAME OF PARENTS’ SHUL
(2)
MEMBERSHIP OF YOUTH GROUPS
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PLACES OF SECONDARY EDUCATION
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NAME AND ADDRESS OF PROPOSED COURSE
INSTITUTION TO WHICH OF STUDY
YOU HAVE APPLIED
DATE OF START OF COURSE YEAR OF STUDY
DO YOU HAVE A CONFIRMED OFFER OF A PLACE ON THE COURSE TO WHICH YOU HAVE APPLIED? YES / NO
(IF NO, PLEASE GIVE DETAILS)
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FROM WHAT DATE DO YOU INTEND TO COMMENCE YOUR STAY AT HILLEL HOUSE, CARDIFF?
SPECIAL REQUIREMENTS
(eg Physical Disablement etc)
DIETARY REQUIREMENTS (Please circle)
Vegetarian / Vegan / Diabetic / Kosher
Level of Kashrut (please give details)
NUMBER OF PERSONS FOR WHOM ACCOMODATION IS REQUIRED
(3)
PLEASE STATE WHY YOU WOULD LIKE TO LIVE IN HILLEL HOUSE, CARDIFF
(Note, this information may be considered in the event of over-subscription for places)
PLEASE GIVE THE NAME AND ADDRRESS OF TWO REFEREES
(1)
(2)
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SIGNATURE DATE
PLEASE NOTE THAT ONLY FULLY COMPLETED APPLICATION FORMS CAN BE CONSIDERED. PLEASE COMPLETE ALL THE SECTIONS
PLEASE RETURN COMPLETED APPLICATION FORM TO;
MRS LISA GERSON lisa@gersonfamily.freeserve.co.uk