Residence Hall Housing Application

Please complete all applicable sections Residence Hall Housing Application.
The areas of red lettering denote required fields.

Student Information
social security number: e.g., 111-22-3333 (must include dashes)
last name:
first name:
middle initial:
date of birth: e.g., mm/dd/yyyy
applying for (select one):
gender:
class year:
country of citizenship:
legal street address:
city:
state:
zip code: e.g., 12345 or 12345-6789  
home phone: e.g., (914) 123-4567
cell phone: e.g., (914) 123-4567
county:
e-mail address:
school:
status:

Student's Address, if different from legal address
street address:
city:
state:
zip code: e.g., 12345 or 12345-6789
home phone: e.g., (914) 123-4567

emergency contact information
name:
relationship:
home phone: e.g., (914) 123-4567
work phone: e.g., (914) 123-4567
work extension:

room selection information
building preference: (1)            (2)
smoker:
room type preference:
roommate preference: (1)

(2)
study preference:
sleep preferences: Prefer to sleep at:
Prefer to wake at:
room condition:
interest(s):

Select ALL Interests that apply:

 

If Other, please identify:
comments: