FALL 2019 & WINTER 2020
Receipt #
Student #
1. Mr.
Ms. Family Name _________________________ Given Name(s) ___________________________________
2. Residence Occupancy Dates:
Preferred Name (Optional)__________________________
Fall 2019 (September 03 to December 18, 2019)
Winter 2020 (January 06 to April 24, 2020)
Spring or Summer (May 04 to June 26, 2020) or (June 29 to August 21, 2020)
3. Gender: Male Female
Date of Birth: Month
____/ Day____/ Year______
4. Permanent Mailing Address (please give complete details):
City/Town______________________________ Province/State_____________________ Country ___________________
Postal Code_________________________ Telephone: Home (______)____________ Work (_____) ________________
(Please include country and city codes)
E-mail Address___________________________________________________________ Fax
(Please include country and city codes)
5. Current Address (if different from permanent mailing address):
City/Town_____________________________ Province/State_____________________ Country ____________________
Postal Code____________________________ Telephone home (_____)___________ Work (____)________________
6. Contact Person Details (In case of emergency):
Name(s)_________________________________________ Relationship to You_________________________________
City/Town____________________________ Province/State_____________________ Country _____________________
Postal Code_________________________ Telephone Home (_____)____________ Work (_____)________________
Please Read and Sign Below (A $25.00 non-refundable application processing fee is required)
Students cannot be accepted into residence until they have been accepted into the Intensive English Program by The Office Use Only: Language
Centre and until they have submitted this application form along with the deposit plus application processing fee of $1,225.00. Once placements have
been made, offers for beds in residence will be faxed or e-mailed. Once a bed is offered, the $1,225.00 deposit and application fee is non-refundable.
This deposit is applied towards the student’s first semester residence fees and is non-refundable and non-transferable. The balance of residence fees
are due upon bedspace confirmation. The University reserves the right to refuse an application for residence accommodation, to cancel residence
privileges at any time, and to reassign students to other rooms for reasons it deems appropriate.
This application is for residence accommodation beginning on the Sunday before the Intensive English Program begins
and ending on the Saturday after the 16 week stay. It excludes the Christmas recess and other breaks between semesters.
It is understood that the University has the right to make regulations under which the student may be permitted to remain
in residence and the student in making this application agrees to abide by all such regulations.
I have read and understood the guidelines and regulations outlined herein and I agree to abide by these guidelines and
regulations, as well as any subsequent additions or alterations which are properly derived or promulgated. I also
understand that Saint Mary’s does not permit smoking in University Residence and agree not to smoke in my room.
Date:_______________________ Signature:__________________________________
(page 1 of 2)
For Office Use Only
$25.00 Rec’d
Student Profile Information
One of the most difficult tasks facing a Residence Life administrator is the assignment of accommodations. In order to
provide more information to assist us in making suitable assignments, you are asked to complete the following
questions. Rooms in residence are assigned on a priority basis taking into consideration (but not guaranteeing) the
specific requests of the student. Students are expected to occupy the room and bed assigned to them.
1. Have you previously applied for Saint Mary’s Residence? (if so, when?)
Yes No Date(s) _____________
2. Have you previously lived in Saint Mary's residence? (if so, when?)
Yes No Date(s) _____________
3. a) Date of birth ? Month____/ Day____/ Year____ (b) Nationality?
4. In addition to your registration in the Intensive English Program,
are you applying (or have you applied) to Saint Mary's as a credit student?
5. In which faculty/program (e.g.,: B.Comm.) are you conditionally admitted
Yes No ID #_______________
(or for which are you applying)? [If applicable]
6. Please state any medical conditions and/or special needs we should be aware of.
7. What are your general interests and/or hobbies?
8. a) Do you smoke? Yes No (b) Would a roommate who smoked bother you?
Yes No
9. If enough demand exists, the Residence Life Office will designate substance-free
Prefer substance-free floor, if available
floors. Neither smoking, nor the consumption of alcohol will be permitted anywhere
Accept substance-free floor, if available
on these floors, including within the students’ rooms. Please indicate preference.
Not interested
10. Designated quiet floors are sometimes available in each residence (although space
Prefer quiet floor, if available
is very limited). These floors are ideal for students who desire extra quiet time during
Accept quiet floor, if available
the day (in addition to the normal quiet hours on regular floors). Preference?
Not interested
11. Designated co-ed floors are available in some residences. On these floors male
Prefer Co-ed floor, if available
and female students live side by side (however, the gender is single-sex within each
Accept Co-ed floor, if available
double room and apartment). Please indicate your preference.
12. Please specify the approximate time of day you retire for bed, and what time
Not interested
you normally start your day on a regular weeknight/weekday.
13. Approximately how many hours per day do you study (outside of classes)?
14. Please indicate your preferred level of orderliness/neatness within your room.
very neat
don’t care
15. Would you prefer a specific roommate (please indicate name), or a roommate from
a specific cultural background (please indicate culture)?
16. Please rank your accommodation
preference from 1-3
(#1 as your 1st choice).
Double Room with no cooking facilities (2 persons in each room)
Single Room with no cooking facilities (very limited availability)
Apartment Bed Space (4 persons in 2 double bedrooms within each
(page 2 of 2)
The Language Centre
Saint Mary’s University
Halifax, NS, B3H 3C3
(Tel) 1-902-496-8275
(Fax) 1-902-420-5122
17 . Any last comments?