SHINSHU KYOKAI
DORMITORY
PPLICATION
Name: _________________________________________________
Valid only when the applicant is accepted and a room assignment is made. Applicant will
complete this form and submit it to the Dormitory office. PLEASE TYPE/PRINT IN INK.
I am applying for residency in Shinshu Kyokai Mission Dormitory for the period (specify the dates):
Beginning _____________________ and Ending ________________________
Special Requests: Lanai ______ Parking _______
Full Name __________________________________________ Signature ______________________________________
Home _____________________________________________________________________ Phone __________________
street city state zip
School to attend _____________________________________________ Major _________________________________
Social Security # ___________________ Age ____ Sex ________ Birthdate ______________ Do you smoke? _____
Are you a U.S. Citizen? Y if “NO,” your country:
Parents (Father, Mother) _____________________________________________ Phone(s) ________________________
Person to call in emergency: __________________________________________ Phone __________________________
You have any chronic ailment, or physical or emotional condition needing consideration in your room assignment,
or FOR EMERGENCY SITUATIONS? ______ If YES, please explain:
Your physician _____________________________________________________ Phone __________________________
Medical Insurance Plan ______________________________________________ Policy # ________________________
Were you ever a dormitory resident? ______ Where? _____________________________________________________
Are you employed? Y Employer ______________________________________ Phone ________________________
E-MAIL: NOTES:
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signature
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