Please check all that apply below:

ANNUAL LODGING APPLICATION

&nbs= p; Lodge Office: (5= 30) 938-5237

&nbs= p; &= nbsp; Fax: (530) 938-5524

A Lodge Licenses/Cont= ract will be sent by mail and must be

on file to reserve a bedspace in the Lodges.

<= o:p>

Name _________________________________________________= _ Gender m Male m Female

= Last = &nb= sp; = &nb= sp; = First = &nb= sp; = Middle Initial =

Social Security Number ____________________ Birth Date ______________

Contact Information

Address ________________________________ Home Phone ________________ Cell Phone _________________

City __________________________ State _= ______ Zip ___________Email Address ________________________

Applying for (check one) m Academic Year 2009-2010 m Spring 2010

What is your major? _______________________Have you applied for Financial Aid? m Yes m No

Do you need special accommo= dations to meet any disabilities? m Yes m No

Are you planning to partici= pate in extra-curricular activities (sports/performing arts/etc.)? m Yes m No

If so, please list: _________________________ __________________________ _________________________

Would you like to share your contact information (phone/email) with a prospective roommate?= m Yes m No

If there is a person you have coordinated being roomma= tes with please list their name(s) here.

_________________________ __________________________

Lodging staff does not guarantee this roommate match w= ill happen, our staff makes every effort to meet these requests.

LIVING HABITS= - Please check all that apply

Sleeping Habits	Cleanliness	Study Habits
m In be= d Before Midnight	m Gener= ally Neat & Clean	m Study= in room w/quiet
m In Be= d After Midnight	m Gener= ally Messy	m Study= in room w/ music
m Early= Riser m Late Sleeper	m Clean= liness Doesn’t Matter	m Study= in Library
Preferences in Music	Roommate Preferences	Are you a Smoker?
mCountr= y &nbs= p; mRap	m Athle= tic m Outgoing	m Yes m No
mClassi= cal &nbs= p; mAlternative	m Quiet= m Same Major	Interested in the Quiet Wing?
mRock/H= eavy mPop	m Studi= ous	m Yes m No

Have you ever been convicted of, or plead guilty or no contest to a felony or misdemeanor crime? m Yes m No

(A “Yes” a= nswer does not automatically disqualify you from housing). In your explanation identify the t= ype of crime and the circumstances surrounding the incident.

Explain______________= ___________________________________________________________________________= _______

_____________________= ___________________________________________________________________________= _______

Do you currently have= a temporary restraining order on file with the court against any individual?<= span style=3D'mso-spacerun:yes'> m Yes m No

(If yes, please provide documentation or see a Lodge Supervisor).&= nbsp;

$100.00 contr= act origination, cleaning and activity fee* must accompany this application= . This $100 Fee is refundable only i= f: 1)You cancel by August 1, 2009, 2)= You are not admitted to the College, or 3)The Lodges are fully occupied at the = time this application is received. Upon receipt of your Activity Fee and application, the Lodge Office will send yo= u a Lodge Contract that must be signed and returned to confirm your reservation.

I understand that dishonest, untrue or inaccurate= or incomplete information submitted on this application or other signed docume= nt is grounds for immediate revocation of the housing contract and/or student discipline, including but not limited to, suspension or expulsion. I understand College of the Siskiy= ous reserves the right to revoke/refuse housing to students or applicants pursu= ant to established COS Board of Trustees policies and/or violations of the lodg= ing license and contract. This application for housing is incorporated by reference and hereby made a part= of the lodging license and contract.

Signature of Applican= t: ___________________________________________________ Date: ________________________

IF APPLICANT IS = UNDER 18 YEARS OF AGE, PARENT OR GUARDIAN MUST SIGN

Signature of Parent/G= uardian: ___________________________________________________ Date: ________________________

*Please make your check payable to College of t= he Siskiyous and mail to 800 College Avenue, Weed, CA 96094