Student Housing Application 2017-2018 

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Please complete all sections of this form. Only completed applications will be accepted. 

Attention Students: In order for your application to be complete it must be submitted with a $25.00 non-refundable 
application fee in money order or check made out to “Lehman College,” and cash is also accepted if you are handing in 
the application in person. Please bring your application fee to Shuster Hall 078 and retain all receipts and records of 
payment. The Office of Vice President of Student Affairs, Shuster 204, does NOT accept any payments. After you fill in the 
application, please retain a copy for your records. 

Term Applying for: Fall 2017-Summer 2018 (Please note the contract period is for 11¾ months) 
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Personal Information (all fields are required) 
First Name Last Name ---


Address 

City State Zip Code 

Home Phone Cell Phone 

E-mail address Social Security # 

A confirmation e-mail will be sent to this address; International students, please provide passport # 

please print carefully. and the country issued. 

Date of birth Gender 

Major Class Status 

 (1st yr, 2nd yr, Grad Student etc…) 

Campus Involvement Macaulay? Y/N 

If you are affiliated with a special program, please enter above. If not, please print ‘none’. 

Room Preferences (Indicating room preferences do not guarantee any specific room assignments due to limited availability.) 

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I’m requesting a: ___ double ($10,006.00/yr., ~$1,668/per installment) ___SMALL single ($11,095.00/yr., ~$1,849/per 
installment) ___LARGE single ($11,820.00/yr., ~$1,970/ per installment) 

Emergency Information (all fields are required) 
Please give information about the person to contact in case of an emergency. ---


 

Name Relationship to you 

Phone (day) Phone (night) 

Allergies 

Indicate all allergies; if you have no allergies please print ‘None’ 

Prescribed medications 

Indicate all prescribed medications; if do not take any prescribed medications, please print ‘None’ 

Medical Information 

Indicate all medical conditions or special needs; if you have none, please print ‘None’ 

Statement of Understanding 
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I understand that submitting a completed application does not guarantee me a space in Lehman Housing and that my 
application might be transferred to the Lehman Housing wait-list due to the limited availability of housing space. As a 
resident, I agree to abide by all College policies as outlined in the Lehman College Student Handbook, and further, I 
agree to abide by the rules pertaining to the residence hall. I understand that I will forfeit my housing agreement if I do 
not make payments according to schedule, attend mandatory meetings and programs, or respond to official postings and 
mailings. I have read and agree to the above statements. 

Signature: _______________________________________ Date: __________________