Graduate Housing Assignment Application
Westchester Office: Ph: (914) 923-2791 Fax: (914) 923-2792
Email: [email protected]
To apply for Housing, you will need to submit this form along with your Housing Deposit ($400) and Security Deposit
($100) to the Office of Student Assistance (OSA). For more information on payment methods, please contact OSA at 914-7733741 or by e-mail at [email protected].
Resident Information is to be filled out by the student only. Please PRINT clearly with black or blue ink when completing this form.
______ Gender: A. Male B. Female
Last Name: __________________________________________ First Name: _____________________________________MI: _________
U Number: __________________________________________ Date of Birth: Month__________ Day ______ Year ____________
Home or Permanent Address:
____________________________________________________
Mailing Address (only if different from home or permanent):
____________________________________________________
____________________________________________________
____________________________________________________
__________________________ __________ ______________
City
State
Zip
__________________________ __________ ______________
City
State
Zip
Frequently used E-mail Address: ___________________________________________
Frequently used Telephone #: (
Major:
) _______________________________Cell Phone #: (
) _______________________________________
Emergency Contact Name: ___________________________________________ Relationship: ___________________________________________
Emergency Contact Home & Business Phone: (
) _____________________________________ (
) _________________________________
Housing Assignment Status & Preference Section (WRITE THE APPROPRIATE LETTER ON THE LINE PROVIDED):
Choices below are not guaranteed.
______ Will be living in residence hall:
A. Fall 2015 & Spring 2016 B. Spring 2016 only
______ Wish to live on the:
A. Briarcliff Campus – Howard Johnson Hall
______ Housing:
A. Lived on campus Spring ‘15
______ Class Credits:
A. Graduate
______ Student Status:
A. Continuing Student
B. ELI Student
______ Study Habits:
A. With music/TV on
B. Without Music/TV on
______ Smoking:
A. Non - Smoker
B. Smoker*
______ Organization:
A. Neat/Tidy person
B. Messy/Sloppy person
C. Mixture of both A & B
______ Bedtime:
A. Bed before 10 PM
B. Bed before midnight
C. Bed after midnight
B. Brand new to campus
C. Resident Prior to Spring ‘15
C. Non-Smoker who does not mind living with a Smoker
_____ Room Preference A. Large Single ($6885 a semester) B. Small Single - if available ($6005 a semester)
*All Residence Halls are smoke free facilities.
Credit Card Authorization for Pre-Payment and/or Deposit
Office Use Only
Cardholder’s Name: _________________________________________
Date Rec’d:_____________ Check #:_________ Amount $:_______
Cardholder’s Cell/Phone: _____________________________________
Building: ________________________ Room __________________
Credit Card Type: ____ Visa
_____ American Express
____ Master Card _____ Discover
Ext: _________________________ Mailbox:__________________
Card Number: ______________________________________________
Rate: ___________________________ HD Entry: _______________
Expiration Date: _____________ Total amount charge: _____________
Notes: __________________________________________________
I authorize Pace University to charge the above credit card number for housing cost.
(Signature) ________________________________________________________
________________________________________________________