EmailMe Form - Foundation Village at Clearfield

Name

First Last

Home Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Local Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Last 4 Digits of
Social Security Number

Student ID Number

Marital Status

Single

Married

Divorced

Widowed

Gender

Female

Male

Parent/Guardian Information

Name

First Last

Relationship

Home Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

General Information

College Enrollment

Yes

No

Current Year at LHU

Enrollment Status

Full Time

Part Time

Name of College

Intended Major

Name of High School

Employer Information

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Employer Phone

### - ### - ####

How Many Months/Years Employed

Monthly Salary

Banking Information

Name of Local Bank

Type of Account(s)

Checking

Savings

Both

Unit and Roommate Preferences

Requests for type of unit, roommate preferences, etc... will be filled on a first-come, first-served basis (based on date completed application and $250 non-refundable fee is received by the Foundation Village Rental Coordinator)

Type of Unit Preferred

2 Bed Unit

4 Bed Unit

Type of Lease Requested
(Physician Asst. graduate students need a 12 month lease)

10 month

12 month

Require a Handicapped Accessible Unit

Yes

No

Are You a Smoker

Yes

No

Names of Roommate Preferences (Optional)

List up to 3 people as roommate preferences

The undersigned hereby offers to rent premises on terms and conditions described herein and upon acceptance of this application agrees to sign a rental or lease agreement and to pay all sums due, including required fees. Application/service fees are non refundable.

Other fees tendered with this application shall be returned to the undersigned if the application is not accepted. The undersigned warrants that the above-stated information is true and correct and authorizes verification of such information, including, but not limited to, verification of employment and rental history.

Signature

Clear

Date Time

MM / DD / YYYY

Foundation Village is owned and managed by the LHU Foundation, 401 N. Fairview Street, Ulmer 214, Lock Haven, PA 17745