Office of Residence Life
On-Campus Housing Application
Please Print
Name:
Last
First
Social Security#:
Middle initial
Date of Birth:
Demographic Information
Permanent/Legal address: (Home)
Number/Street
City
Telephone:
l Single l Married
Will your spouse be living with you? l Yes l No
State
E-Mail Address:
Marital Status:
Gender: Zip
l Female l Male
Spouse’s name:
Accommodations
Please prioritize your first three choices
Clark Tower
Standard . Room
. . . . . . . . . . . . . . . . Single Occupancy
Studio .Apartment
. . . . . . . . . . . . . . . . . . Single Occupancy
2 Bedroom Suite . . . . . . . . . . . Double Occupancy
(Private Bedroom)
License Period
A binding license will be prepared based on your preferred license dates.
l Academic Year (Fall/Spring) l Summer
What program are you enrolled in at ESF?
l Graduate l Undergraduate
Do you need special accommodations due to a disability?
l NO l YES If YES, please explain:
Except for minor traffic violations, have you ever b
een convicted of an violation of the law?
l NO l YES If YES, please explain:
12-0319 Rev. 6/2012
Suitemate Questionnaire
Name:
Program of Study:
This questionnaire is part of an on-campus living program designed to enhance the room and roommate selection
process. Please answer all questions or write in specific information requested. This must be completed before the
roommate assignments can be made. Careful consideration will be given to all your responses. Married applicants/
families do not need to complete questionnaire.
Please note, SUNY Upstate Medical University is smoke-free.
1. Do you have strong feelings against drinking? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. My age is:
l Yes l No
6. Please list 3 special interests or activities in which you
participate:
Would you prefer to live with someone who is:
l younger l older l the same age
3. Would you prefer to live with someone who has
similar interest . . . . . . . . . . . . . . . . . . . . . .
l Yes l No
7. Other roommate assignment factors that I would like
considered:
4. Would you prefer to live with someone in the same
program? . . . . . . . . . . . . . . . . . . . . . . . . . .
l Yes l No
5. Please mark one of the alternatives in each category of
this “self description”:
l Retire early l Retire late
A. Sleeping Habits . . . . . .
B. Room temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thank you for your cooperation
The State University of New York Upstate Medical University does
not discriminate on the basis of race or ethnic origin, gender, age,
religion, disability, marital status or status as a disabled veteran
or veteran of the Vietnam era, in recruitment and employment of
faculty or staff, in the recruitment of students or in the operation
of any of its programs and activities, as specified by Federal and
State laws and regulations.
l Prefer fresh air/cool room
l Prefer window closed/warm room
C. Usual room condition . . . . . . . . . . . . . . . . . . . . . . . . . D. Study Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l Studious l Study when needed
E. Prefer noise level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l Unkempt l Casual l Meticulous
l High l Moderate l Low
Return Application to:
F. Music Preference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l Rock/pop l Alternative l Classical
l Country/Western l Other:
G. Religious attitude(optional): . . . . . . . . . . . . . . . . . . . . Office Of Residence Life
105 Elizabeth Blackwell Street • Syracuse, NY 13210
315-464-5106 • Fax: 315-464-8847
Email: clarktow@upstate.edu
l Strong faith l Moderate l Indifference
FOR OFFICE USE ONLY
Room No.
Accom.
License Period
Room No.
Accom.
License Period
12-0319 Rev. 6/2012