Please complete this form, print, sign and fax it to The Accommodation Manager, WLPMS, on Fax No. 0044 208 967 5083.

1. Candicate Number:
2. Title:	(please select) Mr Ms Mrs Miss
3. Surname:
4. First Name:
5. Nationality:	(please select) Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dominican Dutch Dutchman Dutchwoman East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian I-Kiribati Icelander Indian Indonesian Iranian Iraqi Irish Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese Netherlander New Zealander Ni-Vanuatu Nicaraguan Nigerian Nigerien North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Welsh Yemenite Zambian Zimbabwean
6. Full Home Address:
7. Email Address:
8. Home Telephone Number:
9. Mobile Telephone Number:
10. Please give brief detailed of any medical conditions which you feel should be taken into account when being allocated accommodation:
11. Room Preference: (please select one)	Main Accomodation, provided directly by WLPMS: 1) Single room at £100 per week PRIVATE SECTOR Accomodation, NOT available through or provided by WLPMS (assistance can be given by WLPMS): 2) Sharing the room with another doctor at £50 per week 3) One bedroom family apartment at £300 per week 4) Two bedroom family apartment at £400 per week 5) Three bedroom family apartment at £450 per week
12. Length of Stay:	to
Term of Agreement: WLPMS accommodation is within Ealing Hospital Staff Residences and is occupied under a Licence and not a Tenancy and in accordance with the Hospital Rules. Accommodation will be allocated on receipt of the signed contract and one month rental in advance deposited directly by bank transfer into WLPMS account (details below). These rentals include council tax, gas, electricity and water charges.
I agree the Licence for the accommodation on the terms and conditions above and agree to abide by the Accommodation Rules, a copy of which I will be given on arrival in the UK (please tick box to confirm)
Signed:
Date:

Accommodation Fee

Please pay all accommodation charges along with your tuition fee to the University of Buckingham to the same account to which you pay the fees. The university will acknowledege the receipt of accommodation monies and forward these monies to the relevant hospital.