Application for Residency

Personal Information

First Name (required)

Middle Name

Last Name 0required)

Address 1 (required)

Address 2

City/Town/Village (required)

Province (required)
---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonOther

If "Other" Please indicate Province/State and Country

Postal/ZIP Code (required)

Primary Telephone (With Area Code) (required)

Secondary Telephone (With Area Code) (required)

Your Email (required)

Status on Campus (required)
---MCC Full-time StudentMCC Part-time StudentBuilding Resident Only

Birth Date (DD-MM-YYYY) (required)
Month: ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Date: ---12345678910111213141516171819202122232425262728293031
Year: ---1940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

Marital Status (required)
---SingleMarriedDivorcedSeperated

Social Insurance Number or U.S. Social Security Number (required)

Medical Information

Hospital Card Number

Family Physician's Name

Family Physician's Telephone

Do you have any medical problems the MCC Staff should be aware of?

Primary Emergency Contact - Parant(s)/Guardian(s) (required)

Primary Emergency Contact - Primary Telephone (with area code) (required)

Primary Emergency Contact - Work Telephone (with area code)

Secondary Emergency Contact - Name (required)

Secondary Emergency Contact - Relation To You (required)

Secondary Emergency Contact - Primary Telephone (with area code) (required)

Secondary Emergency Contact - Work Telephone (with area code)

(Required) Applicants are required to send a $150 room deposit to hold their room. By checking this box you acknowledge your intent to send your room deposit as soon as possible.

(Required) I declare that the above are answered fully and accurately. I have read and understood the “Fees and Policy” and “Rules and Guidelines” and I agree to abide fully with all rules and standards therein.

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