Residence Accomodation Application Form


NOTICE To secure your reservation, the $125.00 application fee must be received by: Northwest Community College c/o Registration Office 5331 McConnell Avenue Terrace, B.C., V8G 4X2 *Preferred Roommate If you would like to specify a roommate, both applications must be submitted at the same time.

Please complete all information

Family Name:
First Given Name:
Middle Initial:
Street Address:
City:
Province:
Postal Code:
Email Address
Birthdate:
Gender:	Male Female
Phone Number:
Program Entering:
Term Beginning:
Term Ending:
Room Preference:	Double Room Single Room
Do you smoke?	Yes No
Non-smoking roomate preferred	Yes
Roomate's Name:*
Do you have a car?	Yes No
Licence Number: