THE UNIVERSITY OF TENNESSEE

Department of University Housing

405 Student Services Building

Knoxville, Tennessee  37996-0241

(865) 974-3411

 

 

ROOMMATE APPLICATION

 

 

 

ROOMMATE INFORMATION:

Name: Last: __________________________________ First: ____________________________  Middle: _____________________

Birth Date:  Month _____ Day _____ Year _____  Social Security Number/ID Number:  ___ ___ ___ - ___ ___ - ___ ___ ___ ___

 

 

            Number                                    Street                                                                  City                                                         State                                           Zip
 
Present Address:  ____________________________________________________________________________________________

 

 

            Number                                    Street                                                                  City                                                         State                                           Zip
 
Permanent Address:  __________________________________________________________________________________________

 

Phone: (Work)  ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___             (Home) ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

 

Undergraduate o        Graduate o          Other o Please explain: (Faculty, Staff, etc.) ______________________________________

PERMANENT ADDRESS OF NEAREST RELATIVE:  (parent, brothers, sisters, etc.)

 

Name: __________________________________________________________________ Relationship: _________________________

Address: ____________________________________________ City: ______________________ State/Country: __________________

 

Are you currently enrolled as a student at the University of Tennessee, Knoxville? Yes o        No o 

If No, what semester do you plan to enroll: o Fall Semester _______    o Spring Semester _______   o Summer Semester ______

                                                                                                                                                 Year                                                               Year                                                                                                                                       Year

 

Have you ever lived in UT University Housing before?   Yes o          No o

 

If Yes, please list any names and student ID numbers previously used:

 

 

Name                                                                                                                                                                                                      Social Security Number/ID Number
 
____________________________________________________________________           ___ ___ ___ - ___ ___ - ___ ___ ___ ___

 

 

 

Name                                                                                                                                                                                                      Social Security Number/ID Number
 
____________________________________________________________________           ___ ___ ___ - ___ ___ - ___ ___ ___ ___

 

 

Date:  ____________________________     Signature:  ______________________________________________________________

 

 

PRIMARY RESIDENT INFORMATION:

 

Social Security Number / Student ID Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___                                                                                                                                                    Complex: ________________                                                                                                                                                        Apt. # _________

 

Mr. o      Ms. o

 

Last Name: ________________________________ First Name: _________________________ Middle Name: ___________________

 

 

               The University of Tennessee, Knoxville does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or veteran status in provision of educational programs and services or employment opportunities and benefits. This policy extends to both employment by and admission to the University.

               The University does not discriminate on the basis of race, sex or disability in its education programs and activities pursuant to the requirements of Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990.

               Inquiries and charges of violation concerning Title VI, Title IX, Section 504, ADA or the Age Discrimination in Employment Act (ADEA) or any of the other above referenced policies should be directed to the Office of Diversity Resources & Educational Services (DRES), 2110 Terrace Avenue, Knoxville, TN 37996-3560, telephone
(865) 974-2498 (TTY available). Requests for accommodation of a disability should be directed to the ADA Coordinator at the Office of Human Resources Management,
600 Henley Street, Knoxville, TN 37996-4125.

DUH/8/00   E01-8002-005-01