Central Connecticut State University
Annual Housing Contract Cancellation Form
This form is being submitted to cancel my housing contract. I am aware that any information provided must be verified
by the Department of Residence Life prior to approving this request. You will only be notified if your information cannot
be verified. Any cancellation requests submitted prior to the June 30
th
deadline (or prior to December 1
st
for students
new to housing for the spring term only) will be automatically approved. The $250 housing deposit is non-refundable per
Board of Regents policy.
Name
: ________________________________________________ CCSU ID#:__________________________________
Home Address: ____________________________________________________________________________________
(Street) (City) (State) (Zip)
Cell phone: ________________________________ CCSU E-Mail Address: __________________________________
Housing assignment (Hall and room number if known): __________________________________________________
Current Class Standing: (check one) Freshman / Sophomore / Junior / Senior / Graduate
I am requesting to cancel my housing for: (check one) Academic Year / Spring Semester
I am: (check one) Leaving CCSU / Remaining at CCSU, and just requesting to leave housing
Do you wish to remain on the meal plan: (check one) Yes / No
Reason for cancellation: (check all that apply)
*All reasons must be verified and further documentation may be required.
**
If reason to cancel is for any reason other those listed below, please also read and complete the other side of this form.
( ) Withdrawing from CCSU
( ) Transferring to another College/University
( ) Leave of Absence from University: (circle one) Non-Medical / Medical / Military
( ) Student Teaching / Co-Op / Internship (must be for University credit) (circle one)
*Ple
ase attach proof of the above experience to this form including the name and location of the experience.
**The location must be in closer proximity to your home address than it is to CCSU to be approved.
( )
Study Abroad (please attach proof)
( ) Academic Dismissal
( ) Conduct (No refunds for conduct removals, as noted in the handbook and the contract)
( ) Graduating at the end of the fall semester
( ) None of the above but submitted by established deadline. Reason: ___________________________________
Signature of Student: ________________________________________________ Date:____________
Please Return to the Department of Residence Life in Mid-Campus Hall
Fax 860-832-1659 / ResLife@ccsu.edu / CCSU Dept. of Residence Life, 1615 Stanley St., New Britain, CT 06050-4010
(over)
