Student Housing Information
Secured On-Line Submission Form

Who should complete this form: This form should be completed only by those students
who have been accepted in writing into one of the Long-Term programs of JUC in order to assist the campus manager is selecting suitable roommates. If you have trouble sending the form you may choose to e-mail the information to:
Please Note: If you have already submitted the Student Information sheet from the Long-Term student manual, either by fax, e-mail or letter, you do not need to submit this form.

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Please see our privacy policy for further information.

Personal Information
Today's Date:   	(MM/DD/CEYY)
First Name:     	 Middle Initial:
Last Name:      	
Semester Start Date:	
Home Institution:	
Date of Birth:   	
Are you:		male female
Are you:		single married
Is your spouse:		accompanying you not accompanying you
Phone Number:   	
E-mail Address: 	

Other Information to Help Us Choose Your Roommates:
Are you				talkative quiet in between?
Do you like your music		loud	soft	in between?
Do you prefer			rock	classical jazz other?
Do you get up			early	late?
Do you go to bed		early	late?
Do you prefer to study		in the library in your room?
Do you like your room		neat	super neat casual?
Do you like your room temp	warm	cool?

Is there a particular person you would like to room with?  If so, who?

How do you like to spend your free time?

What quality do you like best in a roommate?

Instructions for Submission
 1) Please review your information before submitting.
2) Click the "submit" button only once.
3) A new screen will appear confirming what has been sent which
you may print out as a record of your submission.


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Last updated on Tuesday, June 05, 2018

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