Application for Housing

Please complete the application below.  Successful completion of this form does not reserve a room.  You must also submit copies of your medical insurance card, meningitis vaccination record, and a $200 refundable deposit.  Rooms are first come first serve with all four parts of the application process complete.

*First Name:
Middle Name:
*Last Name:
*Student ID:
*Date of BirthGender Male FemaleEthnic Origin American Indian/Alaskan Native Asian/Pacific Islander Black/Non Hispanic Hispanic Non Resident Alien White/Non Hispanic
Home Phone Number:
*Student Cell Number:
*Alternate Contact Number:
*Email Address:
*Street Address:
*City:
*State:
*Zip Code:Smoker? Yes NoStay up after 11pm? Yes NoWhat kind of music do you enjoy?CountryRockRapR&BReligiousHip-HopAlternativeAre you an official member of: None Baseball Men's Basketball Women's Basketball Rodeo Volleyball Choir Band DramaPlease list some of your hobbies/interests:First Choice for building assignment: Apartment Traditional New Residence HallSecond Choice for building assignment Apartment Traditional New Residence Hall
Roommate Preference:
Suitemate Preference: May we give your roommate your name and phone number? Yes No
Major (or undecided)Which semester are you applying for? Summer I 2013 Summer II 2013 Fall 2013

I understand that I must submit a $200 deposit, a copy of my meningitis shot record, and a copy of my medical insurance card to complete my application.

Additional Information RequiredYes

I understand that I am responsible for all Panola College policies and rules as outlined in the Pathfinder and the Residence Life Handbook and I agree to abide by these rules.

Policies and ProceduresYes

I understand that Panola College reserves the right to run criminal history reports on all potential residents and that my housing application may be denied based on the results of that report.

Background CheckYes