Housing Request Form Housing Request Form First Name Last Name Email Address Home Phone Cell Phone Gender GenderMaleFemale Marital Status Marital StatusSingleEngagedMarriedDivorced Do you have any children? Do you have any children? No Yes How many? Do you need special accommodations for physical challenges? Do you need special accommodations for physical challenges? No Yes Time you get up: 1-Early 10-Late Time you get up: 1-Early 10-Late12345678910 Time you go to Bed: 1-Early 10-Late Time you go to Bed: 1-Early 10-Late12345678910 Housekeeping: 1-Sloppy 10-Neat Housekeeping: 1-Sloppy 10-Neat12345678910 Noise Level: 1-Quiet 10-Loud Noise Level: 1-Quiet 10-Loud12345678910 Socialize: 1-Some 10-Always Socialize: 1-Some 10-Always12345678910 ACC is an alcohol and drug-free campus, which means as an ACC student you cannot consume or use alcohol or drugs (including marijuana) either on or off campus. On a scale of 1 to 10, how difficult will this policy be for you to follow? 1 - Easy 10 - Difficult If you would like to explain your answer to the above question, do so in the space below. Do you smoke? Do you smoke?YesNo Can you live with a smoker? Can you live with a smoker?YesNo If you would like to request a specific roommate, enter their name here. 2 + 12 = Submit
