Decisions on roommate changes and private rooms will be based on the information provided on
this request form. In general, priority will be given to students with higher academic standing
(Soph v. fresh) and greater number of semesters as residential students.
Name of person requesting room change: ___
___________________Date ______________
Your current apartment: ________________________________ Room: _______________
I agree to pay the additional charges/fees if any
to change rooms. Initial ________
Room Requested# _________________________Bedroom:___________________________
Roommate requested:___________________________________________________________
I am a: _____Sophomore or ____Freshman
I have lived in Millers Crossing for: ______ my first s
emester (OR) _____ previous semesters.
I am requesting a room change because:
I have the following special circumstances: ___________________________________________
Submitted by: _____________________________________ Date: ________________________
(To be completed by Residence Life Staff only)
This request has been approved. The student’s residence hall assign
ment has changed and is now:
____________________________________________________________________ (be specific)
The student has accepted this change and agrees to the charges for the new residence situation.
Changed pricing structure to begin as of this date.
Signature of student: __________________________________ Date: ______________________
Signature of Administrator______________________________ Date: _____________________
The student was offered the following options on t
he designated date and declined the offer
Admin _________ Date ___________ Additional comments: