PURDUE UNIVERSITY SINGLE GRADUATE STUDENT HOUSING APPLICATION

(This application, including rates, policies, and other information, is also available on-line at http://www.housing.purdue.edu)

Apply now to establish priority for University housing

Academic Year

Housing application for:

I am accepted as a graduate student for a Masters

Spring Session

Estimated Date of Arrival? ______/_____/______

Month

Date

Year

or Doctoral Degree in Department of ______________________________ Gender ______________

Male or Female

Purdue University ID Number

_____ _____ _____ _____ _____ -- _____ _____ _____ _____ _____

Full Name

_______
Last

First

Date of Birth ___________/__________/___________

Month
Date
Year

Phone Number

_
(Area Code)

Middle

Current Mailing Address

Street

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 fee.
GENDER
(M - F)

NAME

DATE OF
BIRTH

/
Last, First (Please Print)

PURDUE UNIVERSITY
ID NUMBER

__

__ __ __ __ __ -- __ __ __ __ __

Month Day Year

If you are not requesting a specific roommate, please provide additional information to help us in matching you with a roommate: Assignment
to a room in University Residences is made without regard to race, color, national origin, or sexual orientation. If you do not complete the information
below, we will assume you do not have a preference. All University Residences are non-smoking facilities.

Yes

Do you smoke?

No

Yes

Do you prefer a non-smoking roommate?

No

FURNISHED APARTMENTS (air conditioning included)

No Preference

FOR OFFICE USE ONLY

No pets allowed.

Date Application Received

ONE BEDROOM APARTMENT (Single Occupancy)
_____

Assignment

Purdue Village

TWO BEDROOM APARTMENT (Double Occupancy)

_____

Purdue Village

Indicate your preference of apartment location (not guaranteed):

_____

Upstairs

_____

Downstairs

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 check
card to be used and complete the required information below:

Indicate other specifications you may have

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

_______________________________________________________

Signature of Applicant

Date

AN EQUAL ACCESS/EQUAL OPPORTUNITY UNIVERSITY

Inquiries:
E-mail: ghapp@purdue.edu
Phone: (765) 494-1000

Send Application to:

Fax: (765) 494-0718 or Mail to:
University Residences Directors Office
Purdue University
Smalley Center
1225 Third Street
West Lafayette, IN 47907-2008
Tour our Residences http://www.housing.purdue.edu

CREDIT CARD / DEBIT CARD NUMBER

EXPIRATION DATE
(month / year)

Authorized signature

__

_______