APPLICATION FORM

PLEASE COMPLETE ALL REQUIRED FIELDS.

Effective January 1, 2007, a $30 APPLICATION FEE MUST ACCOMPANY THIS APPLICATION.

YOU MUST BE ENROLLED AT CSUDH IN ORDER TO BE ELIGIBLE FOR ON-CAMPUS HOUSING. This application does not guarantee a space in Housing.

Semester you are applying for: Summer   Fall   Spring    Year:

Last Name: First Name: MI:

SSN / Student ID (leave blank if not known):     Birthdate (MM/DD/YY):

Gender: Female   Male

Class Standing: FR   SO   JR   SR   GR   ESL/ALCP Student

Enrollment Status:

Are you applying to CSUDH through the International Student Services (ISS) Office? Yes No

Address:

City: State: Zip:

Country (if not USA):

Telephone (include Area Code):

Fax (include Area Code):

E-mail Address:

Apartment Type Request (please note that double refers to two persons per bedroom, single to one person per bedroom: 1-Bedroom Double 2-Bedroom Double 3-Bedroom Double 3-Bedroom Single Roommate Request:
Are you a smoker? Yes No (NOTE: All units in University Housing are NON-SMOKING.)
Are you disabled? Yes No
If yes, please comment on your disability:

Please type your information, print, and mail the application to the address below along with a

non-refundable $30 Application Fee. Applications received without the $30 Application Fee will NOT be processed. Please make your check/money order payable to CSUDH Housing.

CSUDH University Housing 
P.O. Box 6228 
Carson, CA 90746-6228