Received:
Deposit
Paid:
Office Use Only
ROOM APPLICATION
Please type or print neatly – illegible or incomplete applications cannot be processed
This application cannot be considered unless there is an active housing deposit being held on the undersigned’s student account. A $200 deposit is required for each student applying for housing.
For payments, please visit or call the Business Office at Mesalands Community College, (575)461-4413x ext. 189. Be sure to identify your payment as a “housing deposit.”
Name: E-Mail:
First
M.
Permanent Address:
Gender: Date of Birth:
City/State/Zip: Phone: Last Four of SSN#:
Freshman
Transfer
Classification, Next Term:
20
Apartments/ Apartment Style Preference:
_____
Bi-level, 2-Bedroom
Apartment, Shared
Occupancy
(one person per bedroom )
_____2-Bedroom
Apartment, Shared Occupancy
;
_____Bedroom A - Double (two persons per bedroom)
_____Bedroom B - Single (one person bedroom)
In compliance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act, Mesalands Community College provides reasonable housing accommodations to students with
disabilities. Students seeking special housing must consult with the Vice President of Student Affairs (575)461-4413, ext. 189.
Mutually Requested Roommate(s):
You can list another student(s) you want to room with. All students wishing to live together must mutually request each other and will be assigned based on space availability.
Compatibility Information: Please check the items that apply to you. When possible, these items are used to match students based on personal & study habits.
Neat Non-smoker
Q
uiet
environment Light sleeper Go
to
bed
BEFORE
10pm
Messy
Smoker*
Music in the background Heavy sleeper Go to bed AFTER 10pm
IMPORTANT! THIS APPLICATION IS LEGALLY BINDING. READ BEFORE SIGNING! The undersigned
has READ AND UNDERSTANDS THE CONDITIONS OF THIS APPLICATION. The student signing understands this agreement is binding for the full academic year
(fall and spring semesters) at Mesalands Community College (Stampede Village) and agrees to abide by all terms of this agreement as stated within. The undersigned agrees to
read and abide by the current Student Housing Handbook published by the Student Affairs Office (available online within the College website: www.mesalands.edu). In
addition, the undersigned also agrees to comply with all other current policies, procedures, and expectations of the College as published online within & via the College
website: www.mesalands.edu. The aforementioned documents further describe the rights and responsibilities of College students & guests and, by reference, are part of this
application. The applicant understands the College may amend, modify or delete any of the aforementioned documents or other College policies without notice. I authorize the
Mesalands Community College/Stampede Village to conduct a detailed criminal background check of my past. Non-disclosure and incomplete or inaccurate information are
grounds for immediate termination of housing.
Student's Signature Date Parent's Signature (if student is under 18 years of age)
Date
Print, Sign, & Return this application to: Student Affairs Office, 911 S. Tenth Street, Tucumcari, NM 88401
MESALANDS COMMUNITY COLLEGE IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY INSTITUTION
page 1 of 1
Summer
There are a limited number of single occupancy rooms. There is an additional charge for single occupancy rooms. Two-bedrooms will be assigned if no single occupancy rooms are available.
Fall & Spring
Returning Resident:
No
Yes
Other________________________
Academic Year:
______
I am:
Very Social
Social
Reserved
My special interests are:
MCC Rodeo
Other; Please Specify:__________________________________________
Last
Family Educational Rights and Privacy Act (FERPA)
I give permission for ___________________________________________________________________, ____________________________________________
__________________________________________________________________, ____________________________________________
to have access to my records regarding (initial all that apply): Housing Discipline Other__________________________________________________________________
Name
Name
Relationship
Relationship
Room:
Office Use Only
Emergency Contact (name and number):
*All apartments are non-smoking. Stampede Village and it's residents will abide by the Dee Johnson Clean Indoor Air Act.
_____1-Bedroom Apartment, Shared Occupancy (two
persons per
bedroom )
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signature
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