7/25/2019 Purdue Village Graduate Housing Application

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PURDUE UNIVERSITYSINGLE GRADUATE STUDENT HOUSING APPLICATION(This application, including rates, policies, and other information, is also available on-line athttp://www.housing.purdue.edu)

Apply now to establish priority for University housing

Housing application for: Academic Year Spring Session Estimated Date of Arrival?______/_____/_Month Date

I am accepted as a graduate student for a Masters or Doctoral Degree in Department of ______________________________ Gender _________Male or Fe

Purdue University ID Number _____ _____ _____ _____ _____ -- _____ _____ _____ _____ _____ Date of Birth ___________/__________/_______Month Date Yea

Full Name _______ Phone Number _Last First Middle (Area Code)

Current Mailing AddressStreet City State / Country Zip Code

What is Your Purdue E-mail Address? (If unknown at this time, refer to next line.)(PLEASE PRINT CLEARLY)

What is your current E-mail Address?(PLEASE PRINT CLEARLY)

ROOMMATE REQUEST: Both roommates, of the same gender, must submit a housing application and nonrefundable application

GENDER DATE OF PURDUE UNIVERSITYNAME (M - F) BIRTH ID NUMBER

/ / __ __________--__________Last, First (Please Print) Month Day Year

FURNISHED APARTMENTS(air conditioning included)

No pets allowed.

ONE BEDROOM APARTMENT (Single Occupancy)

_____ Purdue Village

TWO BEDROOM APARTMENT (Double Occupancy)

_____ Purdue Village

Indicate your preference of apartment location (not guaranteed):

_____ Upstairs _____ Downstairs

Indicate other specifications you may have

(e.g., apartment accessibility, etc.)

_______________________________________________________Signature of Applicant Date

AN EQUAL ACCESS/EQUAL OPPORTUNITY UNIVERSITYInquiries:

E-mail: ghapp@purdue.eduPhone: (765) 494-1000

Send Application to:Fax: (765) 494-0718 or Mail to:University Residences Directors OfficePurdue UniversitySmalley Center1225 Third StreetWest Lafayette, IN 47907-2008

Tour our Residenceshttp://www.housing.purdue.edu

METHOD OF PAYMENT FOR HOUSING FEE

Check or Money Order enclosed -- Payable to: Purdue University

You may elect to use Discover, Visa, or MasterCard to pay the$100.00 nonrefundable housing processing fee. Please checkcard to be used and complete the required information below:

Authorized signature __ ______

CREDIT CARD/ DEBIT CARD NUMBER EXPIRATION DATE(month / year)

/

If you are not requesting a specific roommate, please provide additional information to help us in matching you with a roommate:Assignmen

to a room in University Residences is made without regard to race, color, national origin, or sexual o rientation. If you do not complete the information

below, we will assume you do not have a preference. All University Residences are non-smoking facilities.

Do you smoke? Yes No

Do you prefer a non-smoking roommate? Yes No No Preference

FOR OFFICE USE ONLY

Date Application Received

Assignment

http://www.housing.purdue.edu/http://www.housing.purdue.edu/http://www.housing.purdue.edu/http://www.housing.purdue.edu/http://www.housing.purdue.edu/http://www.housing.purdue.edu/