WIST Application

First Name
Last Name
Middle Initial
Date of Birth
Current Year in School
Major
Are you in good academic standing? (yes or no)
Local/On Campus Address
Address (cont.)
Local/On Campus Phone
Home Address
Address (cont.)
City
State/Province
Zip/Postal Code
Cell Phone
Home Phone
E-mail Address
Place of Employment
Title of Supervisor
Phone # of Supervisor
Length of Employment
Duties and Responsibilities
If Applying with Roommate:
Name of Roommate:
Major of Roommate:
Email address of Roommate:
Please List any Campus Involvement you are or have been involved in:
Personal Statement Please explain why you would like to live at 22 Upper College Rd., what you hope to gain by living in this community, and what qualities you possess that would make you a valuable member of this community.
Disciplinary Clearance
Are you in good disciplinary standing?
If no, please explain:

A letter of recommendation from any faculty member, supervisor, or advisor is
required and is to be presented at the time of your interview.

Your submission below provides consent for the release of information regarding your
disciplinary status from the Dean of Students Office to the Women’s Center Staff.

NOTE: Final selection of residents is left to the discretion of the Women's Center Staff.