7/31/2019 Student Housing Application
1/2
For customer enquiries, phone 131 299*
Student Housing ProgramRiverside Centre, North Tce, Adelaide SA
5000GPO Box 292, Adelaide SA 5001Ph: 8207 0664 Fax: 8207 0380
e-mail: [email protected]
SA is an agency o the Department or Families and Communities
*Calls rom mobile phones will attract a higher cost
1. APPLICATION
DETAILS
PROOFOF
IDENTITYMUST
BEPROVIDED
For example: copy o
passport, birth certifcate
or student ID
Title(e.g. Mr, Mrs, Ms, Dr)
Surname
GivenName(s)
CountryofBirth
DateofBirth//
HomeAddress
PostalAddress(i dierent to above)
Telephone(Home)
MobilePhone
E-mailAddress(i applicable)
()
2. STUDY
DETAILS
PROOFOF
ENROLMENTMUST
BEPROVIDED
For example: copy o letter
rom tertiary institution
confrming enrolment
Nameof
TertiaryInstitution
CourseEnrolled
StudentNumber
ContactPersonat
TertiaryInstitution(e.g Housing Ofcer)
IncomePartner/
ShareTenant
IncomeTenant(e.g. Wages, Austudy)
3. INCOME
DETAILS
PROOFOF
INCOMEMUST
BEPROVIDED
For example: copy o wage
slip, letter rom Centrelink
SourceofIncome WeeklyAmount
$
$
Name
Phone Number ()
AreyouAboriginalorTorresStraitIslander?YesNo
SourceofIncome WeeklyAmount
$
$
Housing SA
Application ForStudent Housing
7/31/2019 Student Housing Application
2/2
Housing SA
Application ForStudent Housing
SHPO1 - ITCH - 07/06
Please return completed application to:
Student Housing ProgramRiverside Centre, North Tce, Adelaide SA
5000GPO Box 292, Adelaide SA 5001Ph: 8207 0664 Fax: 8207 0380
e-mail: [email protected]
SA is an agency o the Department or Families and Communities
4. HOUSING
DETAILS
5. Will any otherpersons be livingwith you?
PreferredArea(s)
No.ofBedrooms(i.e. bedsit, 1, 2, or 3)
SpecialNeeds(i.e. due to a disability ormedical condition)
Friendorrelativeto
becontactedinan
emergency
Name
Relationship
Address
Telephone No(s)
Yes No IfYes,pleasespecify
Full Name Date o Birth Relationship to Applicant Income
6. Have you(or anyperson in question 5 above)
previously been
housed or received
a service from theHousing Trust or
Housing SA?
IfYes,pleasespecifyaddressofpropertyortypeofservice:
DoyouhaveacurrentoutstandingdebtwiththeHousingTrust? YesNo
Haveyoumadeanarrangementtopaybackthedebt? YesNo
I no, contact Student Housing 8207 0664
8. DECLARATION
I declare that the information provided in support of this
application is true and correct.
I have attached copies o the ollowing with the lodgement o this
application:
I understand that the Student Housing Program can be required to
supply information to
Centrelink under the Social Security Act.
1. Proo o my identity 3. income2. enrolment
Applicants Signature Date / /
Yes No
IfYes,pleasespecifyaddressofproperty:
Postcode
Yes No7. Do you(or any personin the previous questions
above)
own residential
property in Australia?
