Residential Life
Office Use Only
Application sent
Application received
Application complete
Cancellation date
Cancellation code
APPLICATION
Middle Tennessee State University
Murfreesboro, Tennessee
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Log No ..
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Please retum the completed application along with the appropriate payment to Housing and Residential Life, P. O. Box 6, MTSU,
Murfreesboro, TN 37132. No assignment will be made until both the application/agreement
and current prepayment are received.
Please print with ink or type.
I am requesting on-campus housing for the following periods:
SPRING TERM 20__
ONLY
SUMMER APPLICATIONS
UPON REQUEST
UNDERGRADUATE
GRADUATE
FAMILY
o Freshman (0-29 hours)
o Upperclassman (30-120+ hours)
o Master's
o Doctorate
o Single with dependents
o Married
o Married with dependents
ACADEMIC YEAR 20 -(Fall and Spring Terms)
APPLICATION TYPE
STUDENT INFORMATION
Legal Name
(do not use nicknames)
Gender
.
Birthdate
(mo., day, year)
M Number
o Male
o Female
High School
Graduation Date
.
Home Address
No., Street, Apt.
Area Code/Student's
City
Cell Phone
Zip
State
Student's
Area Codel
Phone
Country
Email Address
.
Name of parent/guardian to notify in case of emergency
Area Codel
Phone
,"
City
Address
Name
State
Zip
.
Area Code/Parent's
Parent's
Cell Phone
.
Email Address
ALL REQUESTS
Preferences stated are requests only and are not to be understood as contractual stipulations. Preferences may not
be honored due to space limitations. Students checking Learning Communities also must agree to meet and accept all
conditions and terms associated with their assignments. If preferred accommodation type is unavailable, an alternative will
be assigned.
ROOMMATE REQUEST
Mutual roommate requests take priority over building choices or assignment location. If you add a roommate request or a
requested roommate applies later than you, your assignment location could be changed (including a building change) to
accommodate your roommate request. To help insure you receive your requested roommate we make the following
recommendations: 1. Apply early. 2. Apply at the same time. 3. Request the same accommodations. 4. List the same
roommates. 5. Insure roommate requests are mutual.
M Number
Roommate's
'Legal Name
1.
2.
3.
ROOMMATE MATCH
I would prefer a roommate who matches the following:
o Freshman
o Upperclassman
o Older
Student
o Graduate
o Night
o Loud
o Early
Riser
o Tidy
Owl
Music
Student
Do you have a physical disability or cOndition warranting special consideration in making your assignment? 0 Yes ,0 No
Specify special needs
_
(A physician's statement must be attached, if YES. If a seeing-eye dog will accompany you, you must provide a copy of
the dog's credential at the time of application.) We encourage each student with special needs to contact the Disabled
Student Services Office at (615) 898-2783.
FAMILY REQUESTS
At the time of application, all students requesting accommodations for a spouse and/or dependent(s) MUST provide a
copy of a marriage certificate and/or birth certificates for each dependent.
Spouse's legal name (do not use nicknames)
MS Number (for office use only)
Will spouse be a student?
0 Yes
_
,Birthdate (mo., day, yr.)
0 No
_
..
Dependent(s) who will reside with you:
Name (last, first, middle)
8irthdate
MD Number
(for office use only)
Male
Female
Because TCA ~40-39-211 prohibits sex offenders required to register under TCA Title 40, Chapter 39, Part 2 from
knowingly establi~hing a primary or secondary residence or any other living accommodation within one thousand feet
(1,000') of the property line of any public, private or parochial school, licensed day care center, other child care facility,
public park, playground recreation center or public athletic field available for use by the general public, registered sex
offenders are not eligible for housing at our institution. By my signature on page 4, I verify that I am not required to register
as a sex offender under TCA Title 40, Chapter 39, Part 2.
Beginning with the Fall 2013 term, all students under age 22 who are enrolling in a TBR institution for the first time,
regardless of the level at which the student is matriculating, AND who will be living in on-campus housing, must
show proof of adequate immunization against meningitis prior to being assigned to on-campus housing. "Adequate
Immunization" means that students must have been vaccinated on or alter their 16th birthday and within the last
5 years. YOU WILL NOT BE ASSIGNED TO ON-CAMPUS HOUSING UNTIL AN ACCEPTABLE FORM IS ON FILE.
Proof of adequate immunization should be included with this application or returned to: MTSU Health Services, Middle
Tennessee State University, Box 237, Murfreesboro, TN 37132; Phone 615-898-2988; FAX 615-898-5004.
ACCOMMODATIONS
REQUESTS
Select Accommodations Requests in order from 1 to 3. First three requests will be recorded only. Requests for specific
room may be considered for returning students only. Room Number requested:
[M/F refers to Male and
Female]. Accommodation types: Residence Halls-single
[a room specifically designed to house one student]; private [a
room designed to house two students; one student assigned]; shared [a room designed to house two students; two
students assigned]; Scarlett-single
[private bedroom: apt shared by four students]; Womack-private
[one student
assigned to apt].
COMMUNITIES
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Aerospace
Learning Community
[First-Vear Students Only]
Building:
Cummings [M/F]
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Private [limited]
--
Shared
Aerospace
Learning
[Upperclassmen
__
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Private [limited]
Shared
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Cummings[M/FJ
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Smith [MfF]
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Sims[M]
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Room Type:
Single [limited: Smith ONLY]
Private [limited]
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Shared
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Give Me A Beat Community
[FOR RIM MAJORS]
Building:
Sims[MJ
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Beasley [F] __
Smith [M/F]
First-Year Experience
[First~Year Students Only]
Building:
Corlew [M/F]
"Diverse
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World Diverse Arts" Community
SPEECH & THEATRE
Building:
Monahan Complex [M/F]
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Single {limited)
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Private [limited]
Building:
Room Type:
__
Communities
ONLY]
Room Type:
--Shared
Global
Learning
Community
Building:
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Deere Hall [M/F]
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Private [limited]
Shared
Room Type:
Room Type:
__
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Room Type:
Single [limited; Smith ONL YJ
Private [limited)
Shared
--
-[Restricted
--House
-- House
--House
House
--
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1
3
6
8
Greek Row Community
to Greek Memberships
ONLY]
Building:
House 2
-- House 4
-- House 7
Learning Community
Building:
Beasley [F! __
Smith [MfF]
__
Sims 1M] __
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Room Type:
Single [iimited; Smith ONL YJ
Private [limited]
Shared
Women
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In Science
and Engineering
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Beasley [F]
Smith [M/F]
Room Type:
Single [limited; Smith ONL YJ
Private [limited]
Shared
Music at Middle
Building:
Monahan Complex [MfF)
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Room Type:
__
__
--
Room Type:
Single [limited]
Private [limited]
Shared
__
__
Single [limited]
Private [limited]
Shared
--
Pre-Professional
Health and Sciences
Building:
Beasley [F] __
Smith [M/FJ
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True Blue Community
Building:
Nicks [MfFj
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Private [limited]
Shared
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Sims[M]
__
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__
Room Type:
Single [limited; Smith ONL YJ
Private {limited]
Shared
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Traditional
Buildings
[interior}
No Learning Community
Building:
Monahan Complex [M/F]
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Rutledge (M/F]
_Judd
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Lyon Complex [M/F]
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Nicks [M/F]
__
__
Sims[MJ
Room Type:
Single [limited; Monahan, Lyon, Smith
and Rutledge ONL YJ
Private [limited]
Shared
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Private [limited]
Shared
Community
Building:
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Learning Community
Building:
Lyon Complex [M/F]
--
Room Type:
Single [limited; Houses 1, 2, 3, 4, 7 and 8 ONL YJ
Private [limited)
Shared
Nursing
Honors
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Room Type:
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Smith [M/F]
Quad Buildings
[exterior}
No Learning Community
Building:
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Gracy [M/F]
(M/F)
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Beasley [F]
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Apartment
Community
Single Students ONLY
Building:
Womack Lane 1M/F)
Scarlett [M/F]
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Room Type:
One-bedroom, private apt [Womack
Private bedroom, shared apt
Room Type:
Family
Community
Building:
__
ONLY!
Deere [M/F]
Womack
Lane
One-bedroom
Two-bedroom
Room Type:
Semi-Furnished
Un-furnished
Deere [M/F]
TERMS OF APPLICATION AND LICENSE AGREEMENT
This is my application and license agreement to reside in a Middle Tennessee State University residential community. I agree to pay
the required prepayment fees (see current rates) for the academic year for which I am applying. (One-half of the prepayment for spring
term only.) Failure to cancel this application in 'writing by the deadlines stated in the license agreement will result in financial penalties.
By signing this application and license agreement, I accept all terms and provisions of the attached license agreement and understand
the agreement is for the full academic year; including both fall and spring terms (and remaining portion thereof). I agree to accept the
accommodations assigned, I verify all information included in this application is complete and accurate.
Applicant signature,
Spousesignature______
_
Legal guardian signature (if student is under legal age) _
__
_ _
_
Date
_
Date
_
Date
_
MIDDLE
TENNESSEE
STATE UNIVERSITY
1015-2358- Middle Tennessee Slato University does not discriminate against students, employees, or applicants for admission or employment on the basis of race, color, religion. creed.
national origin. SO)(, sexual orientation, gender idontityfexpression. disability. age, status !!IS a protected veteran, genellc Information, or agaInst any other legally protected class with respect to aD
employment, programs. and activities. The following person has been designated 10 handle Inquiries mlaled 10 nondlSCl1m1natJon
policies for MTSU: Assistant to the President for
Institutiona! Equity and Compliance. For additional information about these policies and lhe procedures for resolution, please oont8d Marian V, WlI$on, assistant to the president and
nUe IX Coordinator, Institutional Equity and Complianco, Middle Tennessee Stalo University, Cope Administration Building 116, 1301 East MaIn Street, Murf~boro, TN 37132:
MarianWilson@mtsu.edu;orcan(615)898-2185.MTSU'spolicyon
nondiscrimination can be found BI htlp:llwww.m1$u.eduftiUebrJ.
Certificate of Immunization
MIDDLE
TENNESSEE
MTSU On-Campus Housing Meningitis
STATE UNIVERSITY
Requirement
Beginning with the Fall 2013 term, all students under age 22 who are enrolling in a TBR institution for the first time,
regardless of the level at which the student is matriculating, AND who will be living in on-campus housing, must
show proof of adequate immunization against meningitis prior to being assigned to on-campus housing. "Adequate
Immunization"
means that students
must have been vaccinated on or after their 16th birthday and within the last
S years.
YOU WILL NOT BEASSIGNEDTO ON-CAMPUS HOUSING UNTIL AN ACCEPTABLEFORM IS ON FILE.
PART I
(to be completed by student)
Name
--------------------------------------Last
First
Middle
Date of Birth
_
Student ID No. M
_
PART II
(to be completed and signed by physician)
(Dates must include month and year)
MONTH
DAY
YEAR
MENINGITIS
Meningitis
vaccine must be quadrivalent
to meet requirement.
Meningitis
conjugated
B vaccination
meningococcal
is also recommended
vaccine (MCV4
- Serogroups
by the CDC, but not required
A,C,W-135,&Y)
at this time.
Health Care Provider
(Please print unless office stamp is used)
Name
_
Address
_
Signature
Office phone
Please return to: MTSU Health Services, Middle
Tennessee
State University,
Box 237, Murfreesboro,
_
TN 37132;
Phone 615-898-2988; FAX 615-898-5004
A Tennessee Board of Regents University
MTSU is an equal opportunity,
nonracially identifiable, educational institution that does not discriminate against individuals with disabilities.