Name I Go By (If different from First Name)  

Middle Name

Last Name   

Student ID   
(for some students this will be their Social Security Number)

Home Phone No. 

Cell Phone No.
ex. 903-693-2000

Email Address  
(Failure to submit a valid email address may delay your application)

***************************************************************************************

Residence Hall Request**

First Choice: Apartment Style Rodeo Hall Sharp Hall

Second Choice: Apartment Style Rodeo Hall Sharp Hall

Third Choice: Apartment Style Rodeo Hall Sharp Hall

**We make every effort to place you in the residence hall you request;  however, no rooms are guaranteed.  Failure to select alternate second and/or third choices will indicate that you have no preference beyond your first choice.

Check here if you authorize the release of directory information such as your on-campus phone number and address.

Please list some of your hobbies/interests:

I would like to: Stay in the same room (with the same roommate if they are returning) Change Roommates and if necessary change rooms

Roommate Preference(s)
 

Suitemate Preference(s)

Check here if you want your phone number released to your roommate so that they may contact you before school starts.

I wish to continue living on campus:
Term  Fall Spring Summer I Summer II May Intersession Winter Intersession    Year   

 ******************************************************************************************

I understand that I am responsible for all Panola College policies and rules as outlined in The Pathfinder, and I agree to abide by these rules policies while I attend Panola College.   

  No Yes

My typed name below affirms that the above information is true and correct.

Date

Signature

Click the Submit Form button ONCE to submit your Residence Hall Re-application.

Thank you!