Housing Application - Nursing Program

Student Information
Name * Title First Last Suffix
Gender * Male Female
Smoker * No Yes
Class Status * Sophomore Junior Senior
Semester * Spring Fall
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 - (###) - ### ####
ADA Accommodation Required No Yes
Type of ADA Accommodation Required
Applicant's PSU ID # *

ex. 9-xxxx-xxxx
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
Send Assignment Letter To * Home Address Present Address
DO NOT SEND ANY MONEY UNTILL YOU RECEIVE YOUR ASSIGNMENT LETTER.

Fall 2009 Session/Spring 2010 - $2,213.50 each session. A security deposit of $150.00 is required. Prices include all utilities, but DO NOT include telephone and Cable TV fees.