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First Name *

Your answer

Last Name *

Your answer

Gender *

Male

Female

Email *

Your answer

Phone Number *

Your answer

Your Birthday *

MM-DD-YYYY

Your answer

Social Security Number *

xxx-xx-xxxx

Your answer

Home / Permanent street address *

Your answer

City, State, Zipcode *

Your answer

Please enter your last 2 addresses, if different from permanent

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Please enter your previous landlord's contact information name and phone number

type "no previous landlord" if this is your first time renting

Your answer

Current Employer *

type "not employeed" if you're not currently employeed

Your answer

Employer phone number

Your answer

Have You Ever Filed a Petition For Bankruptcy? *

Yes

Have You Ever Been Evicted From Any Tenancy Or Had An Eviction Notice Served On You? *

Yes

Have You Ever Willfully And Intentionally Refused To Pay Rent When Due? *

Yes

Have You Ever Been Convicted of a Misdeamenor or a Felony Other Than a Traffic Or Parking Violation? *

Yes

Are You A Current Illegal Abuser or Addict of A Controlled Substance? *

Yes

Have You Ever Been Convicted Of the Illegal Manufacture or Distribution Of a Controlled Substance? *

Yes

Which Type of Housing Are you Looking For? *

$975 Per Semester Shared Room

$1395 Per Semester Private Room

$455 Summer Contract Shared Room

$755 Summer Contract Private Room

What semester are you planning on staying? *

Spring

Summer

Fall

Name of Requested Roommate(s)

Your answer

Other Requests (ex: upstairs, basement etc...)

Your answer

How Did You Find Out About Stonebrook? *

Student Housing Guide

Board at SUU / Institute

Friend

Driving

Internet

Flyer

Phone Book

Reffered by SUU

Other:

By ELECTRONICALLY SIGNING and SUBMITTING This Form, I Declare That The Foregoing Is True And Correct, And Authorize Its Verification. *

type your full name as a signature

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