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Summary: Housing Application
NEW RESIDENT STUDENT HOUSING APPLICATION 2010-2011
Office of Residence Life
STUDENT INFORMATION: (ALL FIELDS MUST BE FILLED OUT COMPLETELY)
First Name ______________________________________________________________________________
Last Name ______________________________________________________________________________
Poly ID or SSN#____________________ Gender: Male Female Age ________ Date of Birth _________
Home Address ___________________________________________________________________________
City __________________________ State __________ Zip __________ Country ______________________
CONTACT INFORMATION: (ALL FIELDS MUST BE FILLED OUT COMPLETELY)
Cell Phone # _____________________________________________________________________________
Home Phone # ___________________________________________________________________________
Email Address ____________________________________________________________________________
ROOM PREFERENCES: (ALL FIELDS MUST BE FILLED OUT COMPLETELY)
What type of room are you requesting? Suite Apartment No Preference
Do you have any medical conditions we should know about? __________________________________________
What is your major? _______________________________________________________________________
Are you on an athletic team? If so, what team? ___________________________________________________
(Please fill out remaining information on back)
ACADEMIC INFORMATION:
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