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* Name
Present Mailing Address
City - State - Zip Code
* Phone Number
* E-mail Address
Birth Date
Do You Smoke?
Yes
No
Will You Have a Car?
Yes
No
City and State of Highschool
Phone Number of Highschool
School You Will Be Attending
Winona State University
U of M St. Mary's
Minnesota State SE Technical
When Do You Want to Move In?
Reference #1
Your Relationship to This Person
Phone Number
Reference Name #2
Your Relationship to This Person?
Phone Number
Additional Questions/Comments
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