Date of Application *
First Name *
Last Name *
Preferred Name *
Nationality *
Contact Address *
Email Address *
Phone Number *
Passport Number *
Driver License Number *
Your Age *	18 - 25 26 - 35 36+
Learning Institution
Place of Employment
Course of Study
Expected Length of Stay *
Any Medical Conditions *
Criminal Convictions in Last 7 Yrs *	Yes No
Accommodation Rate (See 'Rates') *	#1 Single $160#2 Twin Share $139#3 Triple Share $130#4 Single $155#5 Twin Share $134#6 Triple Share $130#7 Single $150#8 Twin Share $130#9 Triple Share $125#10 Twin Share $25#11 Twin Share $154
My Agent's Name *
My Agent's Email Address *
My Agent's Phone Number *
I Agree to the Terms Shown Below *	Yes No
Verification:

TERMS:

• I agree to give two weeks notice of my intention to leave Waiariki House
• I agree to abide by the rules and regulations of Waiariki House
• I understand that if I stay less than 30 days I will be charged $25 per night twin share / $30 per
  night single

The most Enjoyable Home in Town!