Landlord:
The Duggan Institute of Dentistry
20311 SW Acacia Street
Newport Beach, California 92660
This Application is made to:
Duggan's Student Housing
For a term of 14 days.On the 14th day students must vacate to premises.
Date of occupancy: February 21 to March 5 2016
Length of occupancy: 14 days (2 weeks)
No. of Bedrooms: 3
No: of Beds: 10
No. of Bathrooms: 3
Females and Males are welcome but will have separate sleeping arrangements
Full kitchen, washer and dryer, dining room
Student Housing Cost
The rent shall be $0.00
The following nonrefundable deposits are required:
Security deposit of $50.00 per studentshall be due upon signature of this agreement.
APPLICANT INFORMATION
Children or spouses that are not enrolled in the course will not be permitted to stay in student housing.
Full Name:
Smokers:Yes _____No _____
Smoking is not permitted in the house. Smoking is permitted outside only. If damage or mess is caused by smoking the students are responsible for the financial cost that may occur from cleaning or replacing damaged property.
PRESENT ADDRESS:
Street #City:State: Zip Code:
Home Phone No: ( )
Emergency contact Name:
Phone No: ( )
Full Name:
Social Security No.:
Visa No:Issuing state:
Driver's License No. : Issuing state:
Damage to Property / Personal Insurance
The undersigned student is financially responsible for any damage they may cause in public or private areas of student housing units. Recommendation letters and certificate of course completion may be withheld for nonpayment of obligations such as lost keys, broken or missing furniture, and general neglectful occupancy of the provided Student Housing.
The Undersigned student understands, acknowledges and waves any future claims to the insurance carried by The Duggan Institute of Dentistry with covers Institute property only and not student housing. And the undersigned agrees to wave or providetheir own insurance for their own protection against loss or damage to property, personal injury, personal illness or liability.
Awareness and Assumption of Risk
I am aware that accepting student housing off Duggan Institute property even under nominally controlled conditions, involves risks including risk of personal injury, death, property damage, expense and related loss, including loss of income. Included in these risks are negligence on the part of The Duggan Institute of Dentistry, its directors, officers, officials and volunteers, other participants and owners of the facilities where the activities occur. I freely accept and fully assume all such risks and the possibility of personal injury, death, property damage, expense and related loss, including loss of income.
Release of Liability, Waiver of Claims and Indemnity Agreement
In consideration of The Duggan Institute of Dentistry accepting my application to participate in this activity, I agree:
- Leave student housing in the condition it was obtained
- Clean, keep order and respect property and other students residing in house
- To waive any and all claims that I may have in future against The Duggan Institute of Dentistry.
- To release The Duggan Institute of Dentistry from any and all liability for any personal injury, death, property damage, expense and related loss, including loss of income that I or my next of kin may suffer as a result of my participation in this activity, due to any cause whatsoever, including negligence, breach of contract or breach of any statutory duty of care.
- .To hold harmless and indemnify The Duggan Institute of Dentistry from any and all liability for any damage to property of, or personal injury to, any third, party, resulting from my participation in this activity.
- That this agreement is binding on not only myself but my next of kin, heirs, executors, administrators and assigns.
I the undersigned represent that the information provided in this Application is true and correct to the best of my knowledge. The Duggan Institute of Dentistry is authorized to verify the references and information given in this Application.
Full Name:
Social Security No.:
Visa No:Issuing state:
Driver's License No. : Issuing state:
Financial information for the security deposit:
Card holder’s Full name
Billing address:
Home phone Number: ( )
Credit card Number:
Expiration:
3 digit security number (located on back of card)
Applicant's SignatureDate
IT IS AGAINST THE LAW TO DISCRIMINATE AGAINST PROSPECTIVE STUDENTS ON THE BASIS OF RACE, RELIGION, NATIONAL ORIGIN, AGE, DISABILITY OR FAMILY STATUS. LOCAL OR STATE LAWS MAY INCLUDE ADDITIONAL CLASSES WHICH ARE PROTECTED FROM DISCRIMINATION IN HOUSING.
The information provided by the prospective student may be used by The Duggan Institute of Dentistry to determine whether to accept this Application. Upon submitting this form The Duggan Institute of Dentistry will disclose within 5 days to the Applicant in writing their acceptance. There must be 10 participating students for the February 22 to March 4 2016 course offering in order for the student housing to be available.
The Duggan Institute of Dentistry Staff Only
Accepted: ______Refused: ______
By: ______