California State University LogoCalifornia State University,Dominguez Hills
International Student Housing Application
1. This is an application for: 

Fall semester,      200___

Spring semester, 200___

Summer semester, 200___

 For Office Use Only: 

  Account # __________________

  Date: ______________________ 

  By:  _______________________ 

  Note:  _____________________
2. Social Security Number, or assigned CSUDH  I.D. number __ __ __ __ __ __ __ __ __ 

(A CSUDH identification number will be issued if you do not have a U.S. Social Security Number.)
3. Legal name: 
_____________________________________________________________________
     Last name                               First name                                                Middle
4.  Mailing address:
_____________________________________________________________________
    Street Number                                   Street name                                                                Apartment number

_____________________________________________________________________

City                                                               State                                       Country                                Zip code
5. Birthday  __ __ / __ __ / __ __
                          Month   Day           Year

6. Sex   ___ Male     ___  Female

 7a. Home telephone      ( __ __ __ )__ __ __-__ __ __ __ 

7b. Daytime telephone  ( __ __ __ ) __ __ __-__ __ __ __

7c. Fax number               ( __ __ __ ) __ __ __-__ __ __ __
8a. Are you currently enrolled?        Yes         No 

8b. Class Standing at beginning of occupancy :       Freshmen     Sophomore     Junior     Senior     Graduate
9a.  Roommate preference  (name of person):  _________________________________ 

9b. I prefer to live with an international student from (name of the country):  _____________________

9c.  I prefer to live with someone who speaks the following languages:   _________________________

9d. I need to house my  ___wife   ___husband     number of children:  _______   Age(s)  _____
10. Type of unit desired:          1 bedroom double / 2 or 3 bedroom double / 3 bedroom single 
    Note: Double refers to two persons per bedroom, single to one person per bedroom
11. Do you smoke?   Yes/No                                         Do you mind a roommate who smokes?   Yes/No 

   Are you disabled?           Yes/No                             If yes, please state disability:  __________________

   Do you have a religious preference?   Yes/No       If yes, please state what religion: _______________
12. I understand that this is only an application and in no way guarantees or implies guarantee of a housing space. 
    Signature: ________________________________________    Date:  _________________
Return completed applications to: 
CSUDH Student Housing P.O. Box 6228, Carson, CA 90749
 Direct all questions to the Housing Office (310) 243-2228 Fax: (310) 516-4275, E-mail: housing@.csudh.edu
Please print the housing application and send it in by mail or fax.

Designed and maintained by Reza Boroon
Last updated: 07/19/2000