Resident Application Form Resident Membership Application Form Reservation number* SECTION A: Applicant DetailsPrefix* First* Middle Last* Date of Birth* DD slash MM slash YYYY Email* Second Email Telephone (Home)*Include country and area codesTelephone (Mobile)*Include country and area codesAddress for Correspondence* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Home, postal or business address for direct mailPermanent Residential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Photograph for Identification Card*Accepted file types: jpg, png, Max. file size: 2 MB.Provide a passport-type photograph, preferably in .jpg format. The photograph is to be: – high resolution – in colour – recent – head and shoulders only – with light background for better printing – with a smile Please make sure you name your file as Photo.SECTION B: Resident MembershipMembership of our prestigious 101 year old international collegium of graduates entitles you to reside in our Melbourne college and use our facilities. Membership is discounted for residents who are enrolled in a course of post-graduate study. The first membership fee includes a Joining Fee. Resident Membership entitles you to free or reduced fee participation in the GU Collegiate events shown in Section Q.Joining Fee Price: Resident Membership Price: SECTION C: Reservation (Booking) for ResidencyHiddenArrival Date Arrival Date Day Month Year Arrival Time* : Hours Minutes AM PM AM/PM Check-in from 2.00pmHiddenDeparture Date Departure Date Day Month Year Number of people*Room Type* Residency Fee per Week* Comments Advance Payment of Residency Fee Price: Minimum two weeks when booked term of residency > 2 weeksRoom Bond Price: Key Bond* Price: Refundable within 14 days of departure date (subject to terms).Car Park* Price: $10 daily or from $190 monthlyInternet Access* Price: $30 per month for 20GB; $40 per month for 50GBSECTION D: Purpose of Visit to Reside at the Graduate UnionPurpose* Study – enrolled for study Other Purpose – e.g., sabbatical, research, teaching, etc. University* Faculty* Department/School* Academic Contact name* Academic Contact email* Academic Contact phone* If enrolled for study, attach documentary evidence of enrolment (or letter of offer) to this application. Evidence of enrolment (or letter of offer)*Accepted file types: pdf, pdf, Max. file size: 128 MB.Please make sure you name your file as fullName_enrolment.pdfStudent Identification Number* Course code and name* Expected date of graduation MM slash DD slash YYYY Course datesYear 1Start Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY Year 2Start Date DD slash MM slash YYYY End Date DD slash MM slash YYYY Year 3Start Date DD slash MM slash YYYY End Date DD slash MM slash YYYY End-award* (e.g., doctorate, professional doctorate, masters, diploma)Purpose of visit* Letter of offer/invite*Accepted file types: pdf, pdf, Max. file size: 128 MB.Please make sure you name your file as fullName_offer.pdfStaff or Visitor Identification Number SECTION E: Tertiary Education Qualifications(for all new graduate Resident Members)Full Name at Graduation* First DegreeYearName of Degree ObtainedUniversityOther Degrees or QualificationsYearQualification ObtainedUniversity SECTION F: RefereesReferees may be contacted at any time prior to or during the term of residency. Please provide details for professional or academic referees (e.g., lecturer, professor, employer, etc.) Do not provide details for family members or friends.Referee 1Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last How long has this referee known you?* What is your relationship to this referee?* (e.g., I was a student or employee of this person)Referee 2Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last How long has this referee known you? What is your relationship to this referee? (e.g., I was a student or employee of this person)SECTION G: Applicant DetailsBirthCountry of Birth* Town/City/Village of Birth* Are you of Aboriginal or Torres Strait Islander heritage?* No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander PassportDo you have a passport?* Yes No Passport Number* Country of Issue* Date of Issue* DD slash MM slash YYYY Expiry Date* DD slash MM slash YYYY Driver’s LicenceDo you have a Driver's Licence in any country?* Yes No Licence Number* Country of Issue* Date of Issue* DD slash MM slash YYYY Expiry Date* DD slash MM slash YYYY Residency StatusPlease choose your residency status in Australia*Australian CitizenPermanent Resident but not Australian CitizenOtherCountry of Citizenship* Visa Type and Number* LanguageOther than English, I use the following languages at competency levels (Low, Medium or High):LanguageCompetency in SpeakingCompetency in UnderstandingCompetency in WritingCompetency in Reading InsuranceMedicare Number(for citizens of Australia only) Private Insurance NumberName of CompanyPhone NumberEmailPolicy Expiry DateAmbulance Subscription NumberName of CompanyPhone NumberEmailPolicy Expiry DateSECTION H: Emergency Contact DetailsIn the event of an emergency The Graduate Union will endeavour to contact the first person listed to inform them of the emergency. If this person is not available, The Graduate Union will endeavour to contact the second emergency contact person listed. Please provide as much contact detail information as possible to ensure that we are best positioned to reach those who love and care about you.Contact 1Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* What is your relationship to this contact?* e.g., I am the daughter/son, friend or patient of this personTelephone (Landline)*Include country and area codes. For calls to overseas, provide best time to call. Telephone (Mobile)*Include country and area codes. For calls to overseas, provide best time to call. Contact 2Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email What is your relationship to this contact? e.g., I am the daughter/son, friend or patient of this personTelephone (Landline)Telephone (Mobile)Doctor in Melbourne If you do not have a doctor in Melbourne you may like to register as a patient with a general practitioner or other health professional at: The University of Melbourne Student Health Services, 138-146 Cardigan Street, Carlton. Telephone: +61 3 8344 6904. This is located within walking distance of The Graduate Union.DoctorName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last TelephoneAddress for Doctor Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home, postal or business address for direct mailSECTION I: Medical InformationIt is recommended that you inform The Graduate Union of any condition that may affect your health, safety and comfort, or the health, safety and comfort of others during your residency. The Graduate Union recommends that you provide this information although its provision is not mandatory. It is collected to assist in providing appropriate residential facilities and services, and in the event of accident or emergency. Information provided to The Graduate Union is subject to the Information Privacy Act 1988, Health Records Act 2001, Equal Opportunity Act 1995 and The Graduate Union’s Privacy Policy.Are you willing to provide details about your health?* Yes No Do you have any of the following: Asthma Stroke Severe Anxiety Head Injury Systemic Infections Major Surgery Back Pain Fits, Seizure, Epilepsy Fainting or Dizziness Depression Schizophrenia Eczema or Skin Disorders Hearing Impairment Visual Impairment Type 1 Diabetes High Blood Pressure Borderline Personality Disorder Habit of Smoking Cigarettes Physical Impairment that affects Mobility Gambling Addiction Drug Addiction Type 2 Diabetes Heart Condition Psychosis Cancer Alcohol Addiction Neck Pain Other (Tick one (at least) or more.)Please provide details (e.g. of allergies) If any of the options are ticked, please provide sufficient information to enable The Graduate Union to provide first aid care and to advise ambulance, paramedic and health care staff in the event of an emergency. This information is kept in your resident records and is treated as private and confidential. It is released only in the event of an emergency to the GU staff and emergency and health services personnel involved in administering care. Additional documents can be attached to this section, such as care plans and the names and contact details of professionals in the care team; medication list, dosages and schedule; known emergency procedure – e.g., in the event of an epilepsy attack, an asthma attack, a psychotic episode, a severe episode of depression or anxiety, hypoglycaemia, etc.; and mobility requirements – e.g., for wheelchair use, bathroom aids, etc.SECTION J: Dietary RequirementsThe Graduate Union provides breakfast seven days a week and dinner five nights a week (Monday to Friday, except Public Holidays) from our college kitchen and bistro. Our college has our own chef and kitchen staff members who come to know and care about our Resident and Non-Resident Members. Note: all meat is Halal.Required Diet (medical certificate required)Please indicate the food that you cannot eat for health reasons (e.g., due to food allergy) Dietary PreferencePlease indicate the foods that you choose not to eat SECTION K: CommunicationsPlease indicate if you would like to receive correspondence and publications via Email.* Yes No SECTION L: How did you learn about our association and college?I was introduced by Member:Name Tick as many as apply Website search for graduate accommodation Website search for meeting services Website search for graduate membership association Word of mouth I discovered this Carlton gem when a member invited me to join them for a member function. I discovered this gem when I attended a meeting, seminar or conference here. Facebook Google Plus LinkedIn YouTube Pinterest Email Mural.ly Twitter PaymentPayment Amount TOTAL $ 0.00 Payment* Paying my own deposit (via Credit Card or Bank Transfer or Direct Debit) Department is paying my account Payment Method* Debit/Credit Card Bank Transfer Direct Debit Financial Institution* Account Name:* BSB:* Account Number:* Swift Code: Start Date:* Day Month Year I would like to give regularly through my selected payment option* I agree to the Automatic Payment Service Agreement Automatic Payment Service Agreement Signature*We acknowledge our Donors I would like my donation to be anonymous and do not wish to have my name printed in any published lists. We will send you a tax invoice (your donation is tax deductible) and include your name in donor lists. Check below if you do not wish to be so acknowledged. Account Name: The Graduate Union of the University of Melbourne Incorporated Bank: National Australia Bank BSB: 083 170 Account Number: 51561 2137 Swift Code: NATAAU3303M Name the transfer as your Surname and the word Resident Form. Please note that your application cannot be processed without receiving payment.Contact Name* Department* Department Email* Debit/Credit Card payments are provided by ‘Stripe’, a third party payment gateway. We do not store your credit card details, or have access to them.Credit Card*Card Details Cardholder Name The Graduate Union will confirm your Reservation within 14 days of receipt of payment.Our FREE gift to you upon becoming a new member of The Graduate Union is a polo or t-shirt. Indicate your preference for a polo (female or male) or t-shirt, and the size of garment required. Tick one option/size.2024 Residential Agreement Terms and Conditions * I certify that the information provided by me, the applicant for residency, is correct, accurate and sufficient to enable The Graduate Union to serve reasonably my comfort and safety, and the comfort and safety of others during my residency. * I authorise The Graduate Union to consent to my receiving emergency medical or surgical treatment as may be deemed necessary, in the event that I am unable to communicate or The Graduate Union is unable to contact an immediate family member/emergency contact. * I authorise The Graduate Union to contact the emergency contacts listed in this form in the event of an emergency and as may be deemed necessary. * I confirm that I will notify The Graduate Union when any of the information changes, that I have provided in this Application Form before and during my term of residency. * I have read and agree to the Residential Agreement Terms and Conditions. * I have attached my letter of offer or other appropriate documentation from the university. * I have attached a digital photo of myself. * I hereby authorise The Graduate Union of The University of Melbourne Incorporated to settle any outstanding debts and penalty fees that I have not settled with cancellation of a confirmed reservation, with early departure from residency and/or prior to departure on my Reserved End Date. * I certify that I will not dispute settlement of outstanding debts and penalty fees that correspond to this Resident Membership Application Form and Residential Agreement Terms and Conditions with The Graduate Union of The University of Melbourne Incorporated. * I have read and understood the Privacy Policy shown at www.graduatehouse.com.au/membership/privacy-policy. * I commit to learn to state the 17 UN agreed 2030 Sustainable Development Goals www.undp.org/content/undp/en/home/librarypage/corporate/sustainable-development-goals-booklet.html * I hereby authorise The Graduate Union to use, reproduce, and publish photographs or videos that may pertain to me, including my image, likeness, or voice without compensation. I understand that this material may be used in various print and digital publications (The Graduate Union newsletter, Melbourne Graduate, Graduate House website and blog, and social media channels, and other marketing material relating to the Graduate Union and Graduate House). I understand that these materials may appear online or in print. This authorisation is continuous and may only be withdrawn by my specific rescission of this authorisation. * I agree to provide a signed copy of the Authorisation sheet within 48 hours of beginning my stay at The Graduate Union. Details for Bank Transfer Account Name: The Graduate Union of the University of Melbourne Incorporated Bank: National Australia Bank BSB: 083 170 Account Number: 51561 2137 Swift Code: NATAAU3303M Name the transfer as your Surname and the word Resident Form. Please note that your application cannot be processed without receiving payment.The Graduate Union will confirm your Reservation within 14 days of receipt of payment.Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
