Caltech Housing: Summer Forms

Please fill out the form below completely. Any items marked with an asterisk are required. Once completed, read the Caltech Summer Guest Housing License Agreement below in its entirety. After you have fully read this section, you may file your application online by clicking submit. You will have a chance to review your information before submission. Section 1 - Personal Information
1.1 NAME, DATE OF BIRTH, GENDER
Please use same name and email address that you used on the research program application (YOUR FULL LEGAL NAME).
First Name*
Middle Name
Last Name*
Date of Birth*	MM-DD-YYYY
Gender*	Male Female
1.2 CURRENT ADDRESS
Current Street Address*
Current City*
Current State
Current Zip
Current Country*
1.3 PERMANENT ADDRESS- Information Same as "Current Address"?
Permanent Street Address*
Permanent City*
Permanent State
Permanent Zip
Permanent Country*
1.4 Phone and Email
Email*
Please retype your email*
Primary Phone*	numbers and dashes only
Alternate Phone	numbers and dashes only
Please only provide a mobile phone number that will be with you while staying at Caltech in the field below; do not input a landline. It will be used to contact you in cases of a campus emergency through Connect-Ed. Connect-Ed is the information notification system adopted by Caltech in 2007, and is the school’s primary tool of emergency notification.
Mobile Phone	numbers and dashes only
1.5 Emergency Contact
Name*
Phone*
Relationship*

Section 2 - Dates of Stay
A Four (4) week minimum stay is required. Arrival time is no earlier than 12:00 p.m.-noon on June 17, 2008, or 9:00 a.m. on any specified arrival date after June 17, 2008. Checkout is no later than 12:00 p.m. on the specified departure date. Please note: Summer housing will only be available between June 17, 2008 and August 23, 2008.
Arrival Date*	MM-DD-YYYY
Departure Date*	MM-DD-YYYY

Section 3 - Caltech/JPL Research Program Information
Program Name
Mentor's Name (Professor)*
Caltech Division / JPL Group
Mentor's Email Address*
Mentor's Phone Number/Extension
Mentor's Mail Code / Stop

Section 4 - Housing Rates, Ranks, and Preferences
Please rank the following in order of preference. Residents will incur an additional $320.00 charge for the Dining Services Meal Plan.
Room Type	Rank	Housing Rate Per Month	Dining Services Meal Plan
North House Double - Loft/Bunk bed, shared bath, community kitchen.		$685.00*	$320.00
South House Single - Lofted bed/desk combos, shared bath, community kitchen.		$755.00*	$320.00
South House Double/Triple - Lofted bed/desk combos, shared bath, community kitchen.		$710.00*	$320.00
The housing rates are effective from June 17, 2008 through August 23, 2008. Rates are subject to change without notice. The room rates listed above do not include linen. You may purchase linen through our office or bring your own. The size of the beds is twin-extra long. If you would rather purchase a set of linen for an additional charge, please check the box. Yes, I would like to purchase a linen pack for an additional $35.00*. The pack includes a set of sheets, towels, pillow and blanket.

Section 5 - Roommate Preferences
Please check all that apply to help us in determining a compatible roommate:
I am a non-smoker	I am a smoker (smoking is not allowed in Caltech housing facilities)
I consider myself a neat and tidy person	I do not consider myself a neat and tidy person.
I prefer quiet in morning (or night-person)	I prefer quiet at night (or early-riser)
Indicate name of preferred roommate, if any:
First Name
Last Name

Section 6 - Other Information
Indicate any medical conditions affecting room assignments or special emergency evacuation needs due to physical disability:
Additional Comments

Section 7 - Your Contract and Submission

By clicking on the agree button, you agree to the terms of this contract.