Student Status:  Freshman  Sophomore
Dormitory Preference:  First Choice: Laker I Laker II 4 Plex      Second Choice: Laker II Laker I 4 Plex      Third Choice: 4 Plex Laker I Laker II
I am Male  Female

Name:  Last    First  Middle Initial
Social Security Number:   
Email Address: (Required)
Cell Phone Number:
Permanent Address: Street/Box  
City      State  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming       Zip 

Parent/Guardian Name(s): 
Mailing Address: Street  
City      State  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming       Zip 
Parent's Home Phone:   Parent's Work Phone:  
Emergency Contact Name:  Phone Number: 

Applying for semester beginning: Fall  Spring  Summer
Year:
Academic Program:
Advisor's Name (if known):

Do you have any special needs to be considered when making your room assignment?
Yes  No  --- If yes, please describe:

Roommates will be assigned in early August.
If known, roommate preference by name:
There is NO guarantee of roommate preference.

List things about yourself that will help with roommate compatibility:
Outgoing     Non-smoker     Quiet Environment     Have Job     Very Neat     Early to Bed 

**ALL DORMS ARE SMOKE AND ALCOHOL FREE**

Sex offender or convicted felon:   Yes     No        
Iowa Lakes Community College has the right to refuse housing.

I certify that all information I have supplied on this application and my supporting documents is true.
 
Name/Signature
Date:  

You may choose to submit this application electronically, or by mail, to the following address:
     Jason McCloud, Housing Coordinator
     Iowa Lakes Community College
     300 S. 18th St.
     Estherville, IA 51334