Application Form - University of Illinois Baptist Church

Housing Application

Baptist Housing Ministry – Rental Applicant Information

House Name

Koinonia Stratford Sutton

Semester(s)

Full Name

Date of Birth

Driver’s License Number

Current Local Address

Permanent Address

E-mail Address

Cell Phone

Are you currently a student at a University/College

Yes No

If yes, name of current University/College

University Identification Number (required

What is your current major

What is your current minor

Do you have any diet restrictions, food allergies, etc.? If so, please explain

Have you ever been convicted of a felony

Yes No

If Yes, what for

Have you ever been evicted from a residence

Yes No

If Yes, what for

Have you ever filed for bankruptcy

Yes No

If Yes, when

Will you want to reserve a parking space

Yes No

Car Make

Car Model

Car Color

Car License Plate

I would describe myself as

Very Neat Somewhat Tidy Untidy

I would describe myself as

Very Quiet Average Noisy

I study

Often Average Seldom

Emergency Contact Name

Relationship to Applicant

Home Phone

Cell Phone

Work Phone

Email Address

Acceptance

Applicant hereby acknowledges by signature below that the information provided in this application is accurate and true. If the applicant has provided false or misleading information, the Baptist Housing Ministry reserves the right to reject the application. Additionally, if a lease has been executed based on this information, the Baptist Housing Ministry reserves the right to terminate the lease and to retain the security deposit and any rent that has been paid.

Applicant's Signature

Date