Central College Intern/Co-op Housing Rental Application

Applicant Information

First Name

Last Name

Address

City

State

Zip

Phone Number (888-888-8888)

Gender

Birthday

Month

Day

Year

Name of preferred roommate

Address

City

State

Zip

Roommate trait preferences / special needs

Internship/Co-Op Information

Employer

Supervisor Name:

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone Number (888-888-8888)

Employer Email

Start Date

End Date

Emergency Contact

Name of a person not residing with you

Emergency Address

Emergency City

Emergency State

Emergency Zip

Emergency Phone Number (888-888-8888)

Emergency Email

Relationship

Consent

I authorize the verification of the information provided on this form as to my credit and employment. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature of applicant:

Date: