AC International House Student Accommodation Application Form

AC International House
Student Accommodation Application Form
A. Personal Details
Surname___________________
First names__________________________
Gender (please circle): Male/ Female Date of birth______/_________/_________
Country of citizenship_________
(dd/mm/yyyy)
Current residential address:
_________________________________________________________________________________________
___________________________________________________________
Mailing address (if different):
_________________________________________________________________________________________
___________________________________________________________
Phone number_______________
Mobile number_______________________
Email______________________
Facsimile___________________________
Institution you are currently studying in:
__________________________________________________________________________
Emergency contact/ Next of kin:
Name______________________
Relationship_________________________
Address__________________________________________________________________________________
____________________________________________________________
Phone number_______________
Do you smoke: Yes/ No
B. Accommodation Requirements
Room type (please circle): Single room/ Double room (if available)
Date accommodation required from_______/________/__________ (dd/mm/yyyy)
Expect length of stay (please circle):
1 semester (20 weeks) 2 semesters( 40 weeks)
Other (please specify) ___________________________
Do you want to apply for a car park: Yes/ No
NB. Limited car parking available at $30 per week.

DECLARATION
Statement to be made by applicant
I hereby apply for a place of residence at the AC International House for the time period indicated on this
application. If admitted, I undertake to adhere to rules and regulations of the House. I understand that nonobservance
may lead me to be expelled from the House and termination of residence.
I acknowledge and agree that the bond money may not be applied by me to the payment of rental money
particularly near the end of my tenancy. This means I am not allowed to stop the payment of rent due before
the end of my tenancy to “use up” my bond money.
I declare the information provided on this form is true and correct and will be relied upon by AC International
House management in processing this application for consideration. I understand that this information will only
be used in accordance with the terms of this application. I authorise AC International Ltd to disclose this
information to relevant organisations.
Signature_____________________
Date______/________/__________ (dd/mm/yyyy)
Please send your completed application form to:
AC International Ltd
Payments to:
2/66 Ghuznee Street Name of bank: National Bank of New Zealand
P.O. Box 6609 Branch: Wellington Commercial
WELLINGTON Address: 1 Victoria St, Wellington, NZ
Account Name: Proswell Ltd
Account Number: 060513 0229679 01
Phone: 04-384 6735
Fax: 04-384 4800
Mobile: 021-666 168
Email: ryoung@acinternational.co.nz
Website: www.acinternational.co.nz
Office Use Only
Application accepted: Yes/ No
Room allocated_________________
• $400 bond (Refundable) Yes/ No
• 20 weeks rent in advance Yes/ No
• $50 Administration & Service fee per semester (non-refundable) Yes/ No
• $75 keys and access card deposit (Refundable) Yes/ No
Amount Paid _______________
Date received______/________/_________