Application For

Student Housing
1. APPLICATION DETAILS
PROOF OF IDENTITY MUST BE PROVIDED
For example: copy of passport, birth certificate or student ID

Housing SA

Title
(e.g. Mr, Mrs, Ms, Dr)

Surname Given Name(s) Date of Birth / / Country of Birth Are you Aboriginal or Torres Strait Islander? Yes No Home Address Postal Address
(if different to above)

Telephone (Home) Mobile Phone E-mail Address

(if applicable)

( )

2. STUDY DETAILS
PROOF OF ENROLMENT MUST BE PROVIDED
For example: copy of letter from tertiary institution confirming enrolment

Name of Tertiary Institution Course Enrolled Student Number Contact Person at Tertiary Institution
(e.g Housing Officer) Name Phone Number ( )

3. INCOME DETAILS
PROOF OF INCOME MUST BE PROVIDED
For example: copy of wage slip, letter from Centrelink

Income Tenant
(e.g. Wages, Austudy)

Source of Income

Weekly Amount $ $

Income Partner/ Share Tenant

Source of Income

Weekly Amount $ $

For customer enquiries, phone 131 299* Student Housing Program Riverside Centre, North Tce, Adelaide SA 5000 GPO Box 292, Adelaide SA 5001 Ph: 8207 0664 Fax: 8207 0380 e-mail: studenthousing@dfc.sa.gov.au www.studenthousing.com.au
Housing SA is an agency of the Department for Families and Communities *Calls from mobile phones will attract a higher cost

Application For
Student Housing
4. HOUSING DETAILS

Housing SA

Preferred Area(s) No. of Bedrooms

(i.e. bedsit, 1, 2, or 3)

Special Needs
(i.e. due to a disability or medical condition)

Friend or relative to be contacted in an emergency

Name Address Telephone No(s) Relationship

5.

Will any other persons be living with you?

Yes
Full Name

No

If Yes, please specify

Date of Birth Relationship to Applicant Income

6. Have you (or any

person in question 5 above)

Yes

No

If Yes, please specify address of property or type of service:

previously been housed or received a service from the Housing Trust or Housing SA?

7. Do you (or any person

in the previous questions above)

Yes

No

If Yes, please specify address of property:

own residential property in Australia?

Postcode

8. DECLARATION

Do you have a current outstanding debt with the Housing Trust? Have you made an arrangement to pay back the debt? If no, contact Student Housing 8207 0664

No No

Yes Yes

I declare that the information provided in support of this application is true and correct. I have attached copies of the following with the lodgement of this application: 1. Proof of my identity 2. enrolment 3. income

I understand that the Student Housing Program can be required to supply information to Centrelink under the Social Security Act.
Applicants Signature Date / /

Please return completed application to: Student Housing Program Riverside Centre, North Tce, Adelaide SA 5000 GPO Box 292, Adelaide SA 5001 Ph: 8207 0664 Fax: 8207 0380 e-mail: studenthousing@dfc.sa.gov.au www.studenthousing.com.au
Housing SA is an agency of the Department for Families and Communities SHPO1 - ITCH - 07/06