Legal Name:  Last  First 
Middle Initial Previous or Maiden Name  
Social Security Number:   
Email Address: (Required)
Permanent 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/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 
Home Phone: Mom:   Dad:

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

I am Male  Female
I will be a Freshman (less than 30 semester hours earned)  Sophomore

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

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

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:
     Housing Office
     Iowa Lakes Community College
     1900 N. Grand, Suite 8
     Spencer, IA 51301