THE UNIVERSITY OF THE WEST INDIES (MONA CAMPUS)
APPLICATION FOR MARLENE HAMILTON HALL (The Studios)
ANSWER ALL RELEVANT QUESTIONS AND TICK APPROPRIATE BOX
PERSONAL INFORMATION
NAME: ______________________________________________________________________________________
(Surname) (First name) (Middle name)
I.D. NUMBER: _____________________________
GENDER: ______________________ MARITAL STATUS: _________________________________
TELEPHONE NUMBER: _____________________________
EMAIL ADDRESS: __________________________________
TERRITORY: _______________________________________
HOME ADDRESS: _____________________________________________________________________________
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MAILING ADDRESS (IF DIFFERENT FROM ABOVE): _____________________________________________
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EMERGENCY CONTACT:
NAME: __________________________________ RELATIONSHIP: ______________________________
CONTACT INFORMATION: Tel #: ________________________ (work/hm) ______________________(cell)
ADDRESS: ___________________________________________________________________________________
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SPECIAL NEEDS: Yes No
If yes, state:
(optional)______________________________________________________________________________
SPECIAL INTEREST: ________________________________________________________________________
ACADEMIC INFORMATION
Faculty: ___________________________________ Department: _____________________________________
Programme: ______________________________ PhD MSc MPhil MEd MA
Level of Study: _____________________ Part time Full time
Date of Commencement: __________________________
Expected Date of Completion: ______________________
Have you resided in a Hall of Residence/ Dormitory before? Yes No
If yes, please state name and period: ________________________________
Floor Preference: 1st 2nd 3rd 4th 5th (not guaranteed)
No preference:
REFERENCES:
Name of Referee: _______________________________________
Occupation: ___________________________________________ Position: _____________________________
Contact Information: Tel #: ___________________________ Email: __________________________________
Address: _____________________________________________________________________________________
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_____________________________________________________________________________________________
Name of Referee: _______________________________________
Occupation: ___________________________________________ Position: _____________________________
Contact Information: Tel #: ___________________________ Email: __________________________________
Address: _____________________________________________________________________________________
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