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PERSONALPleaseprovideyourpersonalinformation.Typeorprintyournameexactlyasitappearsinyourpassport.LastFamilyNameFirstGivenNameMiddleNameMaleFemaleAgeDateoBirthMonthDayYearNationalityNativeLanguageMailingAddressCityProvincePostalCodeCountryTelephoneNumberincludeareacodeEmailThankyouforchoosingIVThisormshouldbereceivedatleast3-4weeksbeoreyourarrival.Wecannotguaranteethatyouwillbeplacedinaroomorwitharoommatethatsatisesallyourpreerences.Youmustbeatleast18yearsoldtoliveintheInternationalVillageIV.PROGRAMPleaseidentifytheprogramforwhichyouveappliedandyourexpecteddatesofstayQuartere.g.WinterYeare.g.2015ProgramNamee.g.APPLengthe.g.9monthsStartDateMonthDayYearMove-InDateMonthDayYearMove-OutDateMonthDayYear1.WhowouldyoulikeustocontactincaseofanemergencyEmergencyContactPersonEmergencyTelephoneNumberEmergencyEmailAddress2.AreyousponsoredbyanagencyembassypartneruniversityYesNoINOskiptoHOUSING.IYESpleaseprovideNameoAgencyEmbassyorPartnerUniversityAgencyIDCountryContactPersonTelephoneNumberEmailAddressHOUSINGPleaseidentifytheInternationalVillageroomtypeforwhichyoudliketoapply.AcademicYear9-monthleaseperpersonpermonthDouble630Single1150Studio118522-weekto9-monthleaseperpersonperdayDouble25Single44Studio4610-to22-weekleaseperpersonperdayDouble28Single49Studio51Lessthan10weeks1-monthminimumperpersonperdayDouble33Single58Studio62Wewanttomakethebestpossiblematchforyourroommate.Pleasecompletethisbriefevaluation1.WhattimedoyouusuallygetupinthemorningBeore7a.m.7-9a.m.Ater9a.m.WhattimedoyouusuallygotobedBeore10p.m.10p.m.-12a.m.Ater12a.m.2.HowimportantiscleanlinessinaroommateoryouVeryimportantSomewhatimportantNotimportantDoyouhavearoommatepreerence3.DoyousmokeYesNoCanweplaceyouwithsomeonewhosmokesYesNo4.HowsensitivetonoiseareyouHighModerateLowWhattypeomusicdoyoupreer5.ArethereanyspecialconditionsthatshouldbetakenintoconsiderationwhenassigningyouaroomroommateDescribebriefyNoteSmokingisonlypermittedoutside.Notintheroomsacility.NoteRoommateswhowishtobeplacedtogethermustrequesteachotherPleasemailfaxoremailyourapplicationmaterialstoInternationalEducationProgramsUCRiversideExtension1200UniversityAve.RiversideCA92507-4596U.S.A.Phone1-951827-4346Fax1-951827-5796Emailiepapplicationucx.ucr.eduForoceuseonlySIDProgramReceivedPAYMENTPayyourapplicationfeewithacashierscheckmoneyordermadepayabletoUCRegentsorbyVisaorMasterCard.CreditCardNumberCardholdersNameExpirationDate3-DigitSecurityCodeAuthorizingSignatureORMoneyOrderorCashiersCheckenclosedREQUIREDIcertiytheinormationonthisentireormiscorrecttothebestomyknowledge.SignatureDateReundCancellationPolicyorIVisonpage20.A200damagedepositisduetoIVuponNoticeoAssignmentNOA.Itisreundableatermove-outminuscleaningandordamagesees.Pricesaresubjecttochangewithoutnotice.On-CampusHousingInternationalVillageApplicationApplicationwillnotbeprocessedwithoutmove-inmove-outdates.