First Name: Middle Name: Last Name:
ID Number:
E-Mail Address:
Net ID:
Gender: (Click here to choose) Female Male Transgender
Graduation Year: (Click here to choose) 2012 2011 2010 2009 2008 Continuing Ed/Non-Degree
Status: (Click here to choose) Currently enrolled UVM student, currently live on campus Currently enrolled UVM student, currently live off campus UVM student planning to return from a leave of absence UVM student planning to return from study abroad Newly admitted first-time, First-Year student Newly admitted Transfer Student Exchange Student, entering Fall 2008 Exchange Student, entering Spring 2009
Academic Major: Academic Minor:
College/School: (Click here to choose) Agriculture and Life Sciences Arts and Sciences Business Administration Education and Social Services Engineering and Mathematics Environment and Natural Resources Nursing and Health Sciences Continuing Education Non-Degree
Room/Box Number: Residence Hall: (Click here to choose) Austin Buckham Chittenden Christie Converse Coolidge Cottages Davis Jeanne Mance Hamilton Harris Hunt Living/Learning A Living/Learning B Living/Learning C Living/Learning D Living/Learning E Marsh Mason McCann Mercy Millis Patterson Ready Redstone Richardson Sichel Simpson Slade Tupper Univ Heights North Univ Heights South Wilks Wills Wing Wright 542 Phone Number:
Street1: Street2 (if needed): City: State: (Click here to choose) Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Zip/Postal Code: Country: (Click here to choose) Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil Brit Ind Ocean Territory Brunei Darussalm Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Islands Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Dem Rep. of Korea Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France France Metropolitan French Guiana French Polynesia French So. Territories F.Y.R. Macedonia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadaloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Heard McDonald Island Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (South Korea) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Mariana Islands Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Island Norfolk Island Northern Mariana Island Norway Oman Pacific Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Korea Reunion Romania Russian Federation Rwanda S Georgia & Sandwich Saint Pierre & Miquelon Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierre Leone Singapore Slovakia Slovenia Solomon Islands Somali Republic South Africa South Korea Spain Sri Lanka St. Helena St. Kitts-Nevis St. Lucia St. Vincent/Grenadines Sudan Suriname Svalbard & Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Tuvalu United States Uganda Ukraine United Arab Emirates United Kingdom Uruguay US Minor Outlying Is. Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands: British Virgin Islands: US Wallis & Futuna Islands Western Sahara Western Samoa Yemen Yugoslavia Zaire Zambia Zimbabwe Home Phone: Cell Phone:
Admission semester: (Click here to choose) Fall 2008 (September) Spring 2009 (January)
Name of Program: (Click here to choose) ALANA House Animalia Arts Initiative RLC: Anime as an Art Form Arts Initiative RLC: Art of Photography Arts Initiative RLC: Clay: Pottery, Sculpture and Arts Initiative RLC: Creative Art Arts Initiative RLC: DANCE: Developing and Achieving Natural Creative Expression Arts Initiative RLC: Fiber Arts and Cultural Patterns Arts Initiative RLC: Inkpot: A Creative Writing Community Arts Initiative RLC: Jewelry Making Arts Initiative RLC: Music Appreciation Community Connection Dewey House for Civic Engagement Ecological World Cuisines Emergency Services Engineering and Mathematics FARMS 2 Plus 2 Dairy Management (VTC-UVM exch stu only) Global Village RLC: Africa House Global Village RLC: Canada House (TAP) Global Village RLC: Caribbean House Global Village RLC: Casa Italiana Global Village RLC: Chinese House Global Village RLC: Das Deutsche Haus Global Village RLC: Exploring Culture through Tea Global Village RLC: Global Social Justice Global Village RLC: Japanese House Global Village RLC: La Maison Francaise Global Village RLC: Latin American Culture and Politics Global Village RLC: Russian House Global Village RLC: Shalom Home: The Israel House Global Village RLC: Spanish House InGEAR: Integrating Gender Equity and Reform Integrated Humanities Program (IHP) (TAP) Integrated Social Sciences Program (ISSP) (TAP) Interpreting Film International Exchange Student Literary Appreciation LIVE: Loving Identity Variations and Equality No Boundaries: Redefining Culture Science Fiction, Fantasy and Horror in the Arts SURF: Scholarly Undergraduate Research Focus Unprogrammed Wilderness Adventure and Naturalist Skills ZZZ: Staff Use Only
> (Click here to choose) Yes No Not sure yet
Preference: (Click here to choose) 1st Choice 2nd Choice 3rd Choice 4th Choice 5th Choice 6th Choice 7th Choice 8th Choice 9th Choice 10th Choice
Preference for L/L: (Click here to choose) L/L is 1st choice L/L is 2nd choice L/L is 3rd choice L/L is 4th choice L/L is 5th choice L/L is 6th choice L/L is 7th choice L/L is 8th choice
I prefer a: (Click here to choose) Suite-style double-occupancy room. Suite-style single-occupancy room (If available, at higher cost.) I would accept a single-occupancy room (at higher cost) if all double rooms in this program are full.
Name of Preferred Roommate: UVM ID Number of Preferred Roommate:
I prefer a: (Click here to choose) A co-ed suite is OK with me (co-ed by alternate room) I would prefer a single-gender suite but would accept a room in a co-ed suite if a single-gender suite is not available in this program. I would NOT accept a room in a co-ed suite.
Please check here if you will be requesting a housing accommodation through the ACCESS Office. Students with disabilities (physical, visual, hearing, learning, psychiatric, systemic/chronic illness, traumatic brain injury, etc.) should contact ACCESS and provide appropriate documentation upon acceptance to UVM to request housing accommodations. The deadlines for requesting housing accommodations are March 17 for returning students and June 30 for first-year students. Students must renew their accommodation with ACCESS each year. Only those accommodations recommended by ACCESS will be considered.
Please place your initials here indicating your agreement with the statement above: