CONTEMPORARY HOME

HOUSING APPLICATION

Month/Year you wish to begin residing in the home:__________________________

Last Name:__________________________ XXFirst Name:___________________________ XXMI:_______

Gender:XXMaleXXFemaleXXXXXXXXSSN#_____________________________ XXBirthdate:___________

DL# (include state) _________________________________

College/University attending:______________________________________ ID#__________________

What is your form of transportation? _________________________

Class standing:

• Freshman
• Sophomore
• Junior
• Senior
• Graduate
• Non-Traditional
• Limited status
• New Student
• Transfer Student

Are you an International student?XXXXYesXXXXNo

If yes, do you have a current visa?XXXYesXXXXNo

What is your major? ________________________________________

Indicate preference: XX Single occupancy XXXXDouble occupancy
 

Current address:___________________________________ XXZip:___________

Telephone number: (XXXX) ___________________ XXFax: (XXXX) _____________________

Cellphone #: (XXXX) ___________________ XXE-mail address: ______________________
 

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Employer’s Name:_____________________________________

Employer’s Phone Number: (XXXX)___________________________

Work address:___________________________________ XXZip:_________
 

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Emergency Contact person(s): Name:__________________________________

Address: _____________________________________

Telephone #: (XXXX) ____________________________

Relationship: _____________________________________

Signature: ____________________________________________________ XXDate: ________________

Note: please provide driver’s license and social security card (visa if applicable) to interviewer upon completion of this application.