1. Complete this form. After reviewing your application click SUBMIT. You will then be taken to a confirmation page where you can PRINT it for your records.

2. After completing the form you must pay the $25 non-refundable application fee.

3. Send checks to: Northern Arizona University, Office of Residence Life, PO Box 6100, Flagstaff, AZ 86011-6100. Credit card payments can be called to 928-523-1122,

4. Marriage must be officially recognized by the State of Arizona. Dependents must be under 18 years of age. If you have more than three children, please contact the

If mailing payment please put applicant's name and University ID number on check

GENERAL INFORMATION
NAU ID Number: (Add leading zeros to get 9 digits, if necessary)	First Name	Middle Initial	Last Name		Birthdate (mm/dd/yyyy) Gender

Permanent Mailing Address		Cell Phone		Phone	E-mail

City		State		Zip	Country

Emergency Contact: First and Last Name				Emergency Contact: Phone		Application For:

Name of Spouse (Family & Couple Applications Only)				Names Children Accompanying you:		Relationship

Spouse's NAU ID Number
Student Type

Have you or any family member planning to live in campus housing ever been convicted of a felony?

If the records have been expunged pursuant to applicable law, you are not required to answer yes to this question. If your answer is yes, you are required to submit a detailed summary of the offense(s) from an appropriate judicial or corrections official, including copies of police reports, sentencing reports or other evidence satisfactory to the University. Your application will be reviewed and you will be notified in writing of the decision regarding your housing request. Failure to disclose an incident will subject you to potential revocation of your on-campus housing.

WORKSHOP INFORMATION		LIFESTYLE REQUESTS* All residence halls are smoke-free buildings
Workshop arrival date		*Preferences are stated only as a request and are not to be understood as contractual stipulations.
	month/day/year	I am a smoker I prefer to live with a:
Workshop departure date		I prefer a single room, if available, at an additional charge:
	month/day/year
Course Code (i.e. EPS 561)		If you will be requesting a residence hall accommodation based on a documented disability, please contact the Office of Disability Resources at 928-523-8773 (523-6906 TTY)
If your housing is being paid by a third party, please be aware that you are responsible for making the necessary payment arrangements.

DEPARTMENT INFORMATION

The Academic department that is sponsoring the workshop

The department contact person

Phone number of contact person

ROOMMATE INFORMATION

First Name	Last Name	NAU ID Number

First Name	Last Name	NAU ID Number

NON-TRANSFERABLE CONTRACT AGREEMENT

If 18 Years of Age or Older: I agree to accept to have my answer as a legal signature to this contract.

By a yes answer I state that I am 18 years of age or older at the time of my submission of this web form. A yes answer is applicable to this housing application.

If Under 18 Years of Age: A parent or legal guardian must give their legal consent on your behalf.

By a yes answer to the following option accept to have my answer as a legal signature to this document as the parent/legal guardian for the applicant. A yes

answer is applicable to this document only.

Parent/Guardian Name (First and Last Name)

Parent/Guardian Drivers License Number State of Issue

I have read and do understand and agree to be bound by the terms of the residence hall contract and the conditions of residence as stipulated on the contract, the Residence Hall Judicial Handbook, the University Code of Conduct, and the Student Disciplinary Procedures. I FURTHER ACCEPT FINANCIAL RESPONSIBILITY FOR THE FULL CONTRACT PERIOD THAT I HAVE STATED ABOVE.

I understand that any violation of university policy regarding alcohol and/or other drugs will result in disciplinary action up to and including termination of this contract. The consumption or possession of alcoholic beverages by anyone under 21, or serving them to anyone under 21, in university residence halls is expressly prohibited.

After completing the form you must pay the $25 non-refundable application fee to complete the application.

Send checks to: Northern Arizona University, Office of Residence Life, PO Box 6100, Flagstaff, AZ 86011-6100.

Credit card payments can be called to 928-523-1122, faxed to 928-523-0009 or made online at nau.edu/bursar.

Residence Life | P.O. Box 6100 | Flagstaff, AZ | 86011 | 928-523-3978

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