Campus Life/Residence Life & Housing/Apply For Housing/Contract Form Contract Form * Indicates required field. Student Information This lease will be for * Full Academic Year (2024-2025) Spring 2024 I am a * 1st Year Student 2nd Year Student (2nd semester or more at Herkimer College) Transfer First Name * Last Name * Email * Date of Birth * Gender M F X Course of Study/Major * H# * Permanent Address * City * State * Zip * Home phone * Cell phone Will you be a registered Full-Time Student at Herkimer College before the first day of classes? Yes No If no, please explain Have you ever been dismissed from Herkimer College or on-campus housing? Yes No If yes, please explain Have you ever been dismissed from another college or other college housing? Yes No If yes, please explain Have you ever been evicted? Yes No If yes, please explain Have you ever been convicted of a felony Yes No If yes, please explain Please upload a photo of yourself (accepted formats: jpg, gif, png) * Parent/Guardian Information Note: Parent/Guardian listed will be emailed a copy of this contract to be notarized. Name * Email * Address * City * State * Zip * Home Phone * Cell Phone * Work Phone * Room Assignment Survey I wish to share an apartment with (list the names of up to four students you would like to request): Full Name Full Name Full Name Full Name Requests will be honored only if all students involved in the request have turned in applications and are not on a waiting list at the time assignments are made and have all requested each other. Assignments are made based on date received. Please number all of the following apartment styles 1 through 6 with 1 being first preference and 6 being last * Please only use each number once Reservoir Run - 1 2 3 4 5 6 4–Person Suite Style Apartment (4 Single Bedrooms) Campus Meadows - 1 2 3 4 5 6 Townhouse (two double bedrooms) - 1 2 3 4 5 6 Two bedroom Flat (one double and one triple bedroom) - 1 2 3 4 5 6 Five Person Flat (one bedroom w/ five students) College Hill - 1 2 3 4 5 6 Single in Two Bedroom Shared Apartment (one single bedroom and one double bedroom) - 1 2 3 4 5 6 Double in Two Bedroom Shared Apartment (one single bedroom and one double bedroom) Do you have any medical conditions that would necessitate special housing Arrangements? If yes, documentation from a licensed medical professional is required and must be sent with this contract. Yes No If yes, please explain Do you go to sleep early? Yes No Are you a quiet person? Yes No Do you study with music on? Yes No Are you a very social person? Yes No Do you like to keep a neat room? Yes No Do you plan on bringing a vehicle to campus? (All vehicles must be registered with the Housing Office upon arrival) Yes No Meal Plan * Please select a Meal Plan Meal 19 Meal 14
