Last Name

First Name

Date of Birth

Gender:  Male Female
Address

City, State  and Zip Code

State, Country and Postal  Code

Telephone  Number

Fax Number

Sponsor or agency name

Telephone Number

Fax Number

Your expected date of arrival (month/day/year)

Your expected date of departure (month/day/year)

Do you have any health needs or requirements to your housing? (Please  describe)

Are you a cigarette smoker? Select Yes No

Is it OK if your roommate smokes? Select Yes No
What is your native language?

Would you  like to room with a person other than your nationality?
Select Yes No
Do you have a specific person you would like to have as a roommate?

Student Signature

Date