Personal Information:
First Name:
Last Name:
Gender:
- Select Gender -
Male
Female
(Ex: MM/DD/YYYY)
Date of Birth:
/ /
Contact Information:
Permanent Address:
City:
State/Province:
- Select State -
- United States -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
California
Colorado
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District of Columbia
Federated Micronesia
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Guam
Hawaii
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Idaho
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Iowa
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Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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N. Mariana Islands
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New Jersery
New Mexico
New York
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North Dakota
Ohio
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Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
US Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
- Canada -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
- Other -
Other State/Province:
Postal Code:
Country:
United States
Aruba
Afghanistan
Angola
Anguilla
Aaland Islands
Albania
Andorra
Netherlands Antilles
United Arab Emirates
Argentina
Armenia
American Samoa
Antarctica
French Southern Territories
Antigua And Barbuda
Australia
Austria
Azerbaijan
Burundi
Belgium
Benin
Burkina Faso
Bangladesh
Bulgaria
Bahrain
Bahamas
Bosnia And Herzegowina
Belarus
Belize
Bermuda
Bolivia
Brazil
Barbados
Brunei Darussalam
Bhutan
Bouvet Island
Botswana
Central African Republic
Canada
Cocos (Keeling) Islands
Switzerland
Chile
China
Cote D'ivoire
Cameroon
Congo, Democratic Republic Of (Was Zaire)
Congo, Republic Of
Cook Islands
Colombia
Comoros
Cape Verde
Costa Rica
Cuba
Christmas Island
Cayman Islands
Cyprus
Czech Republic
Germany
Djibouti
Dominica
Denmark
Dominican Republic
Algeria
Ecuador
Egypt
Eritrea
Western Sahara
Spain
Estonia
Ethiopia
Finland
Fiji
Falkland Islands (Malvinas)
France
Faroe Islands
Micronesia, Federated States Of
Gabon
United Kingdom
Georgia
Ghana
Gibraltar
Guinea
Guadeloupe
Gambia
Guinea-Bissau
Equatorial Guinea
Greece
Grenada
Greenland
Guatemala
French Guiana
Guam
Guyana
Hong Kong
Heard And Mc Donald Islands
Honduras
Croatia (Local Name
Haiti
Hungary
Indonesia
India
British Indian Ocean Territory
Ireland
Iran (Islamic Republic Of)
Iraq
Iceland
Israel
Italy
Jamaica
Jordan
Japan
Kazakhstan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Saint Kitts And Nevis
Korea, Republic Of
Kuwait
Lao People's Democratic Republic
Lebanon
Liberia
Libyan Arab Jamahiriya
Saint Lucia
Liechtenstein
Sri Lanka
Lesotho
Lithuania
Luxembourg
Latvia
Macau
Morocco
Monaco
Moldova, Republic Of
Madagascar
Maldives
Mexico
Marshall Islands
Macedonia, The Former Yugoslav Republic Of
Mali
Malta
Myanmar
Mongolia
Northern Mariana Islands
Mozambique
Mauritania
Montserrat
Martinique
Mauritius
Malawi
Malaysia
Mayotte
Namibia
New Caledonia
Niger
Norfolk Island
Nigeria
Nicaragua
Niue
Netherlands
Norway
Nepal
Nauru
New Zealand
Oman
Pakistan
Panama
Pitcairn
Peru
Philippines
Palau
Papua New Guinea
Poland
Puerto Rico
Korea, Democratic People's Republic Of
Portugal
Paraguay
Palestinian Territory, Occupied
French Polynesia
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saudi Arabia
Serbia And Montenegro
Sudan
Senegal
Singapore
South Georgia And The South Sandwich Islands
Saint Helena
Svalbard And Jan Mayen Islands
Solomon Islands
Sierra Leone
El Salvador
San Marino
Somalia
Saint Pierre And Miquelon
Sao Tome And Principe
Suriname
Slovakia
Slovenia
Sweden
Swaziland
Seychelles
Syrian Arab Republic
Turks And Caicos Islands
Chad
Togo
Thailand
Tajikistan
Tokelau
Turkmenistan
Timor-Leste
Tonga
Trinidad And Tobago
Tunisia
Turkey
Tuvalu
Taiwan
Tanzania, United Republic Of
Uganda
Ukraine
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vatican City State (Holy See)
Saint Vincent And The Grenadines
Venezuela
Virgin Islands (British)
Virgin Islands (U.S.)
Viet Nam
Vanuatu
Wallis And Futuna Islands
Samoa
Yemen
South Africa
Zambia
Zimbabwe
Home Phone:
( ) -
Cell Phone:
( ) -
E-mail Address:
Housing Information:
School:
DeVry University
Keller Graduate School of Management
Ohlone College
Chabot College
Major:
Application Term:
- Select a Term -
Fall 2008 Session A (10/27/2008)
Fall 2008 Session B (1/5/2009)
----------------------------------------------------
Spring 2009 Session A (3/2/2009)
Housing Status:
- Select Status -
New Applicant
Current Housing Resident
Housing Payments:
- Select Type -
Financial Aid Assisted
Cash Only
Emergency Contact Information:
Contact Name:
Relationship:
Address:
Phone:
( ) -
Alt. Phone:
( ) -
Room Assignment Preference:
Room Type:
- Select Type -
Private ($1100 / month - subject to wait list)
Shared ($825 / month)
Triple ($625 / month - limited availability)
Requested Roommate:
In order to help us place you with an appropriate roommate, please fill in the following information about yourself and your lifestyle.
Do you smoke or use tobacco products?
- Select Answer -
Yes
No
*All campus facilities, including Taylor Hall, are smoke-free environments
Do you have a vehicle that you will be bringing?
- Select Answer -
Yes
No
What kinds of music do you listen to? (Please check all that apply)
What are your study habits? (Please check all that apply)
Please evaluate yourself in the following three areas:
Cleanliness:
- Select Answer -
Very Messy
Messy
Average
Clean
Very Clean
Socialness:
- Select Answer -
Very Quiet
Quiet
Average
Outgoing
Very Outgoing
Sleeping Preference:
- Select Answer -
Extreme Night Person
Night Person
Average
Morning Person
Extreme Morning Person
Please provide any additional information about yourself and/or your roommate preference:
Additional Background Information:
Have you ever been convincted of or pled guilty or "no contest" to any felony?
- Select Answer -
Yes
No
Have you ever been convincted of or pled guilty or "no contest" to a sexual offense?
- Select Answer -
Yes
No
If you answered "Yes" to either question, please explain: