Apply to become a Resident

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth

MM

DD

YYYY

Name *

Next of Kin

First Name

Last Name

Address *

Reference 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Reference 2

Country

(###)

###

####

Do you have a lasting Power of Attorney set up? *

Yes

No

Do you have a lasting Power of Attorney set up? *

Yes - for my Health & Welfare

Yes - for my Financial Affairs

Yes for Both

No- I don't have a LPA appointed

Permission to keep on file Checkbox

Please indicate if you permit Partis College to retain your personal details for up to six months for the purpose of future vacancies.

Yes

No