On-Campus Housing Application

Indicates required fields.

Personal Information
First Name:
Last Name:
Street Address:
City:
State:	Zip
Phone (Home): (xxx) xxx-xxxx
Phone (Work): (xxx) xxx-xxxx
Email Address:
Employer Enter "NA" if not employed
Have you ever been enrolled at MSU, CWV, or Beckley College?	Yes No If yes, when?
Birth Date: mm/dd/yyyy
Social Security Number: xxx-xx-xxxx International Students enter 000-00-0000
Gender:	MaleFemale
Emergency Contact Information
Person to contact in case of emergency
Phone (xxx) xxx-xxxx
Relationship
Academic Information
Applying for Term Beginning
Classification at Beginning of Term
Roommate Preference
Do you prefer a roommate who is___ (Scale: 1 = very, 5 = not at all)
Quiet/Reserved	12345
Outgoing	12345
Neat/Orderly	12345
a Morning Person	12345
a Night Person	12345
likely to prefer quiet hours to study	12345
studying in a similar major	12345
from a similar geographic area	12345
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 $150 room reservation fee, 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.

Please click the Submit button only once.

Network problems may be keeping your request from being processed. If you do not receive a confirmation page in the next few seconds, please contact Kimberly Bess by phone at 800.766.6067 x 1474 or by email kbess@mountainstate.edu to verify that your application was recieved.

Legal Statement | ©2009 Mountain State University. All Rights Reserved. Mountain State University is authorized under federal law to enroll nonimmigrant alien students. Mountain State University is accredited by the Higher Learning Commission and a member of the North Central Association (312.263.0456, www.ncahigherlearningcommission.org).