Roommate Application

City
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Marital Status
- Single
- Married
- Divorced
- Widowed
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone
Emergency Contact
Emergency Contact Name
First Last
Emergency Contact Phone
Emergency Contact Email

Housing Needs
Arrival Date*
MM slash DD slash YYYY
Departure Date*
MM slash DD slash YYYY
What is your maximum rental budget?
What is the purpose of your visit?
- School
- Internship
- Research
Address of Your School or Employer*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Private Bath
- Yes
- No
Will you have the use of an automobile?
- Yes
- No
How did you hear about our program?
Please write a brief note to your roommate, describing what you would like them to know about you:

Arrival Information
Airport pickup?
- Yes
- No
Arrival Information
Reservation
To reserve your accommodation, we require a one-time, non-refundable placement fee of $100. This fee guarantees your placement. You may pay your placement fee by credit card, wire transfer or bank draft. Once you submit this form, we will contact you to make payment arrangements.
By clicking below, you are certifying that the information provided above is complete and accurate. You are also acknowledging that you have read and understood our legal notices, and that you are at least 13 years old.

Emergency Contact