Elm Tree Lodge

Application

 

 

Surname_________________________________

 

Given Name______________________________

 

Date of Birth______________________________

 

Sex___________________

 

Nationality______________________________

 

Home Address____________________________________________________

 

Length of Stay at Elm Tree Lodge:  From_____________   To_______________

 

Institution Attending________________________________________________

 

Courses Attending_________________________________________________

 

Postgraduate/ Undergraduate/ Exchange_______________________________

 

Phone_____________________

 

Mobile_____________________

 

Fax_______________________

 

E-Mail__________________________________________________________

 

Car Park Required____________

 

Smoking_______________

 

Use of Cooking Facility: Daily/ Weekly/ Occasionally______________________

 

 

Next of Kin_______________________________________________________

 

Address_________________________________________________________

 

Contact.  Phone___________________________________________________

 

(Complete this form and email to admin@elmtreelodge.com.au or fax to 08 83722555)

 

Please note incomplete form will not be processed.