Palmerston House

Personal Details

Name *
Date of Birth * / DD / MM YYYY
Passport No *
Email *
Agent Name
Course of Study

Surname *
Country of Birth *
Driving License No
Gender * Male Female
Institution to Attend
Student ID

Parent Details

Father's Name *
Address *
Country *
Telephone
eg. (65) 9988 7766
Mobile
eg. (65) 998 87766

Mother's Name
Email
Fax eg. (65) 9988 7766

Room Details

Room Type *

A - Single Bedroom (Small)
B - Single Bedroom (Medium)
C - Single Bedroom (Large)
D - Twin Share Bedroom (Medium)
E - Twin Share Bedroom (Large)

Comments

I, the above-named applicant, have read this application form in conjunction with the information sheet provided. I understand that this is a Fixed Terms (44 weeks) agreement and that the reservation payment will not be refunded if I cancel the booking at any time. I further agree to abide by the House Rules and regulations as attached and acknowledge that any breach by me of these Rules and Regulations may result in the termination of my stay without any refund of rental monies paid at the discretion of Palmerston House.