The University of Texas Health Science Center at Houston

UNIVERSITY HOUSING
Phase II

APPLICATION FOR RENTAL

Date: ______________________
NAME __________________________________________________________________ DATE OF BIRTH ___________________
CURRENT ADDRESS: _______________________________________________________________________________________
Are you transferring from UT Housing? No ___
GENDER:

Male ____

UT-HOUSTON:

Female _____

Medical ______

M.D. ANDERSON _____

POSITION:

Yes___

If Yes, What is your current Apt. #:_________________________

E- mail address:________________________________________________________
Dental______

BAYLOR _____

Student _______

Public Health_______
IBT _____

Staff _______

Nursing ______

GSBS______

SHIS______

OTHER ___________________________________

Faculty_______

Resident_______

Fellow _______

Home Phone:_________________________ Cell Phone:_____________________________ Work Phone:_____________________

List information about your spouse, boyfriend/girlfriend, or any other adult family member occupying the apartment:
NAME __________________________________________________________________ DATE OF BIRTH ___________________
GENDER: Male
UT-HOUSTON:

Female

Medical ______

M.D. ANDERSON _____

POSITION:

RELATIONSHIP: ______________________
Dental______

BAYLOR _____

Student _______

E- mail address: ____________________________

Public Health_______
IBT _____

Staff _______

Nursing ______

GSBS______

SHIS______

OTHER ___________________________________

Faculty_______

Resident_______

Fellow _______

Home Phone:_________________________ Cell Phone:_____________________________ Work Phone:_____________________

List all individuals under the age of 18 (eighteen) occupying the apartment:
Name __________________________________Age ________

Name ____________________________________Age _________

List all vehicles to be parked on the premises by the applicant. (Boats, trailers, or recreational vehicles are not permitted):
Make _________________________ Color _____________________ License Plate # ____________________ State ____________
Make _________________________ Color _____________________ License Plate # ____________________ State ____________
Your drivers license # __________________________ State ___________ Spouses # ____________________ State ____________
IN CASE OF EMERGENCY NOTIFY ________________________________Phone # _________________ E-mail______________________
UNIVERSITY OF TEXAS STUDENTS ONLY UNDER THE HIGHER EDUCATION OPPORTUNITY ACT OF 2008, YOU ARE ENTITLED
TO IDENTIFY A CONFIDENTIAL CONTACT PERSON WHO IS TO BE CONTACTED NOT LATER THAN 24 HOURS FOLLOWING A
DETERMINATION THAT YOU ARE MISSING. IF YOU WISH TO DESIGNATE A CONFIDENTIAL CONTACT PERSON OTHER THAN THE
PARTY IDENTIFIED ABOVE, PLEASE DO SO BELOW. IF NO ADDITIONAL PERSON IS IDENTIFIED BELOW, THE EMERGENCY
CONTACT NOTED ABOVE WILL BE CONTACTED IN THE IN THE EVENT OF A DETERMINATION THAT YOU ARE MISSING.
CONFIDENTIAL CONTACT PERSON ______________________________ Phone # _________________ E-mail______________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Type of housing desired: TWO BEDROOM Unit 1__________
Unit 6__________
Unit 7___________
ONE BEDROOM Type of lease term:

_____ 6 months

Unit 2________ Unit 3________ Unit 4________ Unit 5___________

Desired Month of Move-in:_____________________

_____ 12 months

Next section for University Housing office use only

Apartment number assigned:________________________

Rental rate $_________________ Move-in date ___________________

Amount of deposit _____________________ Date deposit received_____________________ Lease starts _____________________

This application is made with the understanding that it is subject to acceptance by University Housing. In the event the above applicant fails to
enter into the contemplated lease, University Housing shall retain the deposit in order to cover the cost of taking and processing this application.
The Waiting list fee is NONREFUNDABLE. Leasing office hours are Mon-Fri., 8 a.m. to 6 p.m.
__________________________________________________
University Housing Representative

_____________________________________________________
Signature of Applicant

__________________________________________________
Date

_____________________________________________________
Signature of Applicant