Residence Hall Application & Contract 2013-2014

Student Information

Student's First Name:
Student's Last Name:
Birthdate:
Gender:
Permanent Address:
City:
State:
Zipcode:
Country:
Home Phone:
Cell Phone:
E-mail:
*Parent's E-mail:

* To receive Residence Life newsletter.

Emergency Contact:

Emergency Contact Name:
Emergency Contact Phone:
Relationship:
Address:
City:
State:
Zipcode:
Country:
Same as Permanent Address:

Academic Information

Academic Major:
Semester Entering UDM:
Class standing (as of Fall 2013):

Lifestyle Preference

Are you:
How tidy are you:
Do you smoke:
Do you object if you roommate smokes:
Your room is for:

Other (specify):
Of all the above lifestyle questions, which would you say are the most important considerations for you in choosing a roommate:

Housing Options

I want to live on a Women in Science and Engineering floor (First year women - Shiple Hall only):
I require special accommodations:
Describe your special accommodations:

Additional Information

I have been convicted of a felony:

Residence Hall and Room Preference

Residence Hall Preference: Please rank the following (1-6)

Shiple Hall (First Year Experience):
Holden Hall:
Suite Style Hall (Upperclass/Graduate students only):
North Quad:
South Quad:
East Quad:
West Quad:

Room Type Preference (Please rank 1-2):

I prefer a double room:
I prefer a single room:

I request a specific roommate. Both persons must request a match and both contracts must be received by July 19, 2013:
Roommate's Name:
Roommate's Phone:
Roommate's E-mail:

Board Plan Options

Choose any board option. The 9 meal option will be assigned for those who do not select a plan, West Quad residents included.

19 meals/$200 Titan Cash:
9 meals/$200 Titan Cash:
210 block plan/$375 Titan Cash:
No Meal Plan - West Quad residents only:
Co-Op Plan - co-op students only:

I acknowledge and agree to the terms and conditions in this contract. I agree to abide by the terms of this Contract and agree that all information submitted on the form is accurate. Falsification of any information may result in revocation of this Contract and/or disciplinary action. Note: The Office of Residence Life will make every effort to accommodate your requests. However, we may not be able to fulfill any request.