RESIDENCE HISTORY: List all the University residences where you have previously lived:

CURRENT RESIDENCE INFORMATION:

Current Residence: ____________________________________			Current Room No: __________________
Current Type of Room:		Single room
		Two-room double with roommate or live-in attendant		Two-room double without roommate or live-in attendant
		One-room double with roommate or live-in attendant		One-room double without roommate or live-in attendant
		Apartment with roommate or live-in attendant		Apartment without roommate or live-in attendant

TYPE OF ACCOMMODATION REQUEST: Complete option A, B, or C, below, and please indicate how your disability impacts your housing needs and why you are requesting an exemption from or accommodation within the regular assignment process. Please be as specific as possible about requests for architectural modifications and other requirements. You may attach additional sheets if needed.

A.	I request an exemption from the standard housing application process.
B.	I can participate in the standard housing application process, but I request a specific accommodation within my residence or within my room.
C.	I am in housing for the 2000-01 year, and I am requesting to be reassigned to a different type of room or residence.

Please describe:

REQUIRED MEDICAL DOCUMENTATION: You must provide documentation from an appropriate professional describing your disability. Please refer to Documentation of Disability for guidelines. A copy of these guidelines should be provided to any professional providing documentation.

	I have attached the required documentation.
	Current documentation is already on file at the Disability Resource Center. (Please contact the Disability Resource Center if you have questions about the need to submit additional documentation.)

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