University Village Application IndentificationName* First Last SAU Student ID#Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Date of birth* Gender* Male Female Email Enter Email Confirm Email Student InformationAre you a commuter?* Yes No Current Residence HallSemester you are applying for:*Fall 2014Summer I 2015Summer II 2015Academic Year 2015-2016Check where applicable:*60+ HoursOver 21MarriedVeteranSingle Parent4 semesters in Residence Halls50+ Hours with a 3.25GPAHousing OptionsApartment Type*2 Bedroom/1 Bath4 Bedroom/2 BathFamilyContract Type*9 Month12 Month12 Month- EarlyIndicate any special health problems or disabilities that should be considered in making housing assignment. Have you ever been convicted of a felony or sex-related crime?* Yes No If yes, please explain. Meal OptionsAll students will be on a $400 declining balance if a plan is not chosen.Meal Plan$400 Declining Balance$500 Declining Balance5 Meals plus $160 Declining Balance10 Meals plus $140 Declining BalanceUnlimited Meals plus $75 Declining BalanceUnlimited Meals plus $125 Declining BalanceRoommate Request(s)Once you are admitted to University Village, be sure you and your roommate(s) request the same unit. Roommate requests and/or assignments will not be processed until all applicable fees and deposits have been received. Due to space limitations, requests may not be honored. Ask about roommate matching.Name 1Name 2Name 3PaymentsThe only way to secure your room at University Village is to return a completed and signed application, proof that you are eligible, and pay the $200 deposit. Please return application and checks to Housing Office, PO Box 9431, Magnolia, AR 71754. In the event of cancellation, your $200 deposit will be forfeited.