*First Name

*Last Name

*Middle Name

*Social Security

*Sex Male Female

*Date of Birth 01 02 03 04 05 06 07 08 09 10 11 12 | 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 | 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

*Are you a transfer student? YES NO

If yes, name of college/university

Class Standing Freshman Sophomore Junior Senior Graduate

*Applying for Fall Term Winter Term Summer Term

Module # Fall 1 Fall 2 Fall 3 Fall 4 Spring 1 Spring 2 Spring 3 Spring 4 Summer 1 Summer 2 Summer 3 Summer 4

*Email

*Street / P.O. Box

*City

*State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

*Zip Code / Postal Code

*Country

*Phone

*Contact Person's Full Name

*Street / P.O. Box

*City

*State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

*Zip Code / Postal Code

*Country

*Phone

Please the following questions in order to help us make the best matches possible. We will attempt to meet special requests can not guarantee them.

Specific person you would like as a roommate

What time do you prefer to study? Morning Afternoon Evening Night

Where do you prefer to study? Room Library Other

If other, where?

Are you a smoker? YES NO

Would you share a room with a smoker? YES NO

What is your major?

SIU Athletic Team, if any?

I typically go to bed at 10 p.m. - 12 a.m. 12 a.m. - 02 a.m. After 02 a.m.

My favourite type of music is

My hobbies are

I uderstand that acceptance of this application does not guarantee assignment to a residence hall or admission to the University. I have also read and understand the terms of this application as stated under Residence Halls Policies.

Check the box if you agree with the above statement