2009-2010 Columbia Residence Hall Application

Permanent Address Information
First & Last Name*   (Please fill in all * fields)
Address*
City*
State*
 
ZipCode*
 
Email* (Necessary to send confirmation)
       
Date of Birth*
 

Gender*
Female
 Male

Class*
Freshman
Sophomore
Junior
Senior
   

 

Emergency Contact Information
 
Name*
Address*
City*
State*
Zip Code*
Daytime Phone*
Relationship*
 
  Evening Phone*

 

Housing Request
I prefer the following accommedations (please choose your 1st, 2nd, and 3rd choice for your room assignment by writing a 1, 2, or 3 in the box next to the choice):

Double Share

Double Alone (2x Doube Share Rate)

Single

 Yes
 No

If we are not able to place you in your choice of housing, are you willing to accept any room that we might have available?
   
Yes
 No		 Are you currently a CCON resident?

If requesting a DOUBLE SHARE, the person with whom I would like to share a room is:

 

Please indicate any special needs that should be taken into account as room assignments are made:

Meal Plan*
 No Meal Plan
Plan 1 ($1,100 including fee)
Plan 2 ($1,600 including fee)
Plan 3 ($1,900 including fee)

+ The above prices are for the entire academic year

College Attending*
Columbia College of Nursing
Columbia St. Mary's Schools
University of Wisconsin - Milwaukee
Other *Click here for housing eligibility

  
 

* Enter your intials here if you have read the 2009 – 2010 Residence Hall Contract Books & Housing Application. Please print out a copy of this document to keep for your own records.

* Enter your initials here to act as your signature. You certify that you are requesting a room at the Columbia College Residence Hall and all of the above information is correct.

If you have a printer, you may want to print this page for your records before you submit the form.