Registration and Application for Entry

Please attach two recent digital photos of the applicant

I hereby apply to reside at Kathleen Lumley College

From Until

1. Personal Details
Name
Address
Telephone
Fax
Email
Place of Birth
Date of Birth
Marital Status
Male/Female	Male Female
Have you ever suffered from or are you at present suffering from any major illness or disability?
2. Next of Kin
Name
Address
Telephone
3. Education Record
(Degrees, University, Year Conferred)
4. Details of Tertiary Course to be pursued during residence at Kathleen Lumley College
University
Department/School
Degree	Ph.D. Masters Postgraduate Diploma Other
Mode	Full-time Part-time
Due to graduate
Supervisor
Usually working at (address)
Telephone
Extension
5. Previous Residence in Colleges/Halls
Have you been a resident of a College/Hall at a tertiary institution?
If YES, give details
6. Extra Curricular Interests

If accepted as a resident of Kathleen Lumley College, I agree to pay all residental fees and charges when due, to abide by the College regulations, and to give not less than four week's written notice of my intent to give up residence.