PERSONAL DETAILS Pease fill in all the sections using BLOCK LETTERS only Please affix photograph here Name of Applicant as per IC/Passport Passport /IC no : ___________________________ Nationality : ___________________________ Date of Birth : ____________________________ Gender : Religion : ____________________________ Marital status : Male Female Single Married Mailing address : ________________________________________________________________________________ __________________________________________________ Postcode: __________________________________ Home Telephone : _____________________________ Mobile : __________________________________ E-mail :___________________________________________________________________________ Programme : __________________________________________________________________________ Intake : April July September others : _______ Year: ____ EMERGENCY CONTACT Name : _________________________________________________________________________________ Address : _________________________________________________________________________________ Relationship :_____________________________ Contact No: _________________________________ ACCOMMODATION & TYPE OF ROOM (Please tick to indicate your choice) D’Pulze Cyberjaya Twin-sharing Ensuite Serin Residency Cyberjaya Twin-sharing Non-ensuite A B Twin-sharing Ensuite A B Single Non-Ensuite A B MEDICAL HISTORY/ ALLERGY If you are physically disabled, please state the nature of the disability. If not, please write “Nil”. _______________________________________________________________________________________________ Any medical condition which may be of concern (Eg:Allergy). If not, please write “Nil”. _______________________________________________________________________________________________ CONFIRMATION & DECLARATION I, ________________________________________________________________________ (Student’s name) hereby, a) confirm my understanding that this accommodation application is subject to room availability and that the University reserves the right to assign any other type of accommodation available. b) confirm that I have read the General Accommodation Rules and Regulations, and agree to abide the said rules and regulations. c) agree that the period of my accommodation is from first day of the semester until the last day of the same semester and my maximum stay is up to one year. d) understand fully that if I violate any of the said Regulations, I will be expelled from the unit. e) understand that in the event of my expulsion, my rental for the unexpired accommodation period will be forfeited, my deposit refunded less. f) any deductions due to the University for damage caused to the unit and/or its contents (if any) and /or for excess utility consumption. g) declare that all information given by me is complete, accurate and true. Any information given falsely or withheld will affect my application and/or agreement. h) submit the total payable payment slip together with the submission of the application form for accommodation for processing by HWUM. i) Rental is EXCLUSIVE of water, electricity and sewerage (Indah Water) bills, which will be coordinated by HWUM and billed directly to me. j) Cancellation - a Penalty of one month rental will be imposed, if I decide to cancel and/or withdraw from accommodating the unit after reservation is made. _______________________________________ ___ ________________________________________ Signature of Student/ Applicant Date Accommodation Unit Only Finance Office Only Received By : __________________________ Payment method : __________________________ Received Date : __________________________ Amount paid : __________________________ Residence Name : __________________________ Receipt No. : __________________________ Date : __________________________ Unit & room Assigned : __________________________ Payment can be made: Mode of payment Account Name Bank Account No Bank Address Swift Code : Cash, Cheque or Telegraphic Transfer : Heriot-Watt University Malaysia Sdn Bhd : Malayan Banking Berhad (Maybank) : 5140-1102-2817 : Floor 8, Menara Maybank, 100 Jalan Tun Perak, 50050, Kuala Lumpur, Malaysia : MBBEMYKL