Housing Application - Med/Grad Student

Student Information
Name * Title First Last Suffix
Gender * Male Female
Smoker * Yes No
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Present Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email *
Home Phone * - (###) - ### ####
Present Phone * - (###) - ### ####
Cell Phone - (###) - ### ####
Fax - (###) - ### ####
ADA Accommodation Required Yes No
Type of ADA Accommodation Required
Applicant's PSU ID #

ex. 9-xxxx-xxxx
Family Information
Spouse/Domestic Partner/Other First Last
Child 1: Name First Last
Child 1: Date of Birth / MM / DD YYYY
Child 1: Gender Male Female
Child 2: Name First Last
Child 2: Date of Birth / MM / DD YYYY
Child 2: Gender Male Female
Vehicle On-Campus
Make/Model/Year
License Plate #
State
Roommate Preference
1^st Preference First Last
2^nd Preference First Last
3^rd Preference First Last
Please select one of the following * MD Student Graduate Student MD/PhD Program
Class Year/Department/Program *

If you are a MD Student enter your class year. If you are a Graduate student, enter your department. If you are a MD/PhD student, enter which program.
Requested Date of Occupancy * / MM / DD YYYY
Note: Vacate date requires notification as per lease/contract.

Indicate 1^st, 2^nd and 3^rd choice

DO NOT SEND ANY MONEY UNTIL YOU RECEIVE YOUR ASSIGNMENT LETTER. Present rental rates as well as security deposits are shown. Prices include all utilities, but DO NOT include telephone and Cable TV fees.

Unit	Rates	Security Deposit
One Bedroom (No Children)	$808.00	$200.00
Two Bedroom with Washer/Dryer	$954.00	$200.00
Two Bedroom with Washer/Dryer - Shared	$477.00 pp	$150.00 pp
Three Bedroom (Must have 2 children living on-campus)	$1045.00	$200.00

1^st Choice *
2^nd Choice
3^rd Choice

Housing Application - Med/Grad Student

Student Information

Family Information

Vehicle On-Campus

Roommate Preference

Indicate 1st, 2nd and 3rd choice

Indicate 1^st, 2^nd and 3^rd choice