Application for Residency

Admissions – Step Two

This is your “Application for Residency” form. Before filling out this form be sure to read the Fees and Policy and Rules and Guidlines for residency.

Make sure all information provided is accurate and up to date. Once you submit this form return to the top of this page and proceed to Step Three.

Personal Information

First Name (required)

Middle Name

Last Name 0required)

Address 1 (required)

Address 2

City/Town/Village (required)

Province (required)

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)

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

Marital Status (required)

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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503 University Ave Charlottetown, PE Canada C1A 7Z4
Phone: (902)628-8887 | Fax: (902)892-3959
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