(circle one)

Single Bed Loft System -- $175
Double bed Loft System -- $350

(per academic year)

Permanent Address: __________________________________________________________

City: ____________________________  State: _____________________________ Zip: ______________________

(circle one)        Crofton       Camp       Escalante      Cooper      

Room Number ______________  Residence Hall phone number: ___________________________

Roommate's Name, when available (for double loft only) _____________________________________________

Credit Card # _____________________   Expiration Date: _____________

Name appearing on Card: ________________________________________   Last 3 or 4 digits on back of the credit card______________

visa        mastercard     discover   (circle one)

*Refund policy:  There are no refunds on beds that have already been set-up in the designated rooms. If not attending school a 90% refund will be made if nodified before move-in day.