Personal Information
First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
US
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
--
India
Japan
Nepaul
Pakistan
Turkey
Uzbakistan
Vietnam
China
Africa
Other
Zip
Phone (Home):
Phone (Work):
Email Address:
Employer Enter "NA" if not employed
Have you ever
Yes No If yes, when?
Birth Date:
Social Security Number: *International Students enter 000-00-0000*
Gender:
Male Female
Emergency Contact Information
Person to contact
Phone
Relationship
Academic Information
Applying for Term Beginning
Select Term
Fall
Spring
Summer I
Summer II
Full or Part Time
Select One
Full Time
Part Time
Classification at Beginning of Term
Select One
Freshman
Sophomore
Junior
Senior
Intended Major
Housing Preference
First choice
University Hall (single room only, available beginning fall 2010) Hogan Hall, double room Hogan Hall, single room
Second choice
University Hall (single room only, available beginning fall 2010) Hogan Hall, double room Hogan Hall, single room
Have you ever been
Yes No Explanation if yes
Have you ever been convicted of a
Yes No Explanation if yes
Roommate Preference
Do you prefer a roommate who is___ (Scale: 1 = very, 5 = not at all)
Quiet/Reserved
1 2 3 4 5
Outgoing
1 2 3 4 5
Neat/Orderly
1 2 3 4 5
a Morning Person
1 2 3 4 5
a Night Person
1 2 3 4 5
likely to prefer quiet hours to study
1 2 3 4 5
studying in a similar major
1 2 3 4 5
from a similar geographic area
1 2 3 4 5
Request a specific roommate
By submitting this form you are acknowledging
that you have read and understood the Residence
Hall Terms .
Note: All efforts are made to accommodate requests but there is no guarantee that all requests will be fulfilled.
Note: Mountain State University reasonably accommodates persons with disabilities.
Please contact the Housing and Residence Life Office for additional information.
This application does not admit you to the University.
After submitting this housing application, you must send the required $200 housing application fee/room reservation deposit (unless you are applying for exemption), payable to Mountain State University, to the Housing and Residence Life Office, Box 9003, Beckley WV 25802-9003. We cannot accept checks drawn on international banks.
