Housing Application - Short Term

Student Information
Name * Title First Last Suffix
Gender * Male Female
Smoker * No Yes
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 No Yes
Type of ADA Accommodation Required
Applicant's PSU ID #

ex. 9-xxxx-xxxx
Vehicle On-Campus
Make/Model/Year
License Plate #
State
Please check one of the following * Medical Student Resident Post Doctoral Fellow Graduate Student Other
Class Year/Department/Type of Student *

Medical Students should enter their class year. Residents, Post Doctoral Fellows, and graduate students should enter their department. Other students should enter which type of student they are.
Requested Date of Occupancy * / MM / DD YYYY
Expected Vacate Date * / MM / DD YYYY
DO NOT SEND ANY MONEY UNTILL YOU RECEIVE YOUR ASSIGNMENT.

Short Term Rate (furnished apartment) - $466.00/month or $35.00/day for less than a month. You are required to sign a lease and pay a $150.00 security deposit.
Room Selection * University Manor West