Please list preferred roommate:

First Last Email Phone

First Last Email Phone

First Last Email Phone

My preferred apartment style is:

The following information will be used for roommate matching only.  Please complete this section as if you were talking to a prospective roommate and keep in mind that your honesty will benefit both you and your roommates. Check all items that apply.

Studying:

Where I Study	How Much I Study	When I Study
I prefer to study in my bedroom	I study less than 1 hour/day	I prefer to study in the morning
I prefer to study in the living room	I study 1-3 hours/day	I prefer to study in the afternoon
I prefer to study at the library	I study more than 3 hours/day	I prefer to study at night

Other people consider me to be:

Are you interested in living in a Mixed gender apartment? Yes   No

Special considerations or accommodations:

I like to keep the apartment temperature: 70 or below   70 to 75   75 or above  

How did you hear about Palmer Student Housing? Choose one Walk-in Website Facebook Instagram Twitter The Signal Craigslist Palmer College Website Apartments.com Other:

Capstone On-Campus Management, LLC supports the Fair Housing Act as amended, prohibiting discrimination in housing based on race, color, religion, sex, national origin, handicap or familial status. All applicants and/or guarantors are subject to a criminal and/or credit check with approval through a third party applicant screening agency and follow the standards below to include, but not limited to: We do not accept prospective residents currently on parole, probation and/or suspended sentence for any conviction, or who have been charged with, pled "guilty" or "no contest" to, and/or convicted of any felonies, certain misdemeanors, or any unlawful conduct involving a minor.

CITIZENS:

• Complete a standard application form and housing agreement package.

NON-CITIZENS:

• Complete a standard application form and housing agreement package.
• Provide a passport.
• I-20 verifying student status and proof of enrollment or appropriate work visa verifying country of origin and length of employment

Applicant understands that to secure use of a bedroom within an apartment, he/she must complete all housing Agreement paperwork and pay all fees. Applicant understands that if, at any time, there are un-rented bedrooms in the applicant's assigned apartment, Capstone On Campus Management (COCM), as Agent for Palmer College Foundation, reserves the right to assign roommates without prior notice and/or relocate the applicant to another unit. Applicant further understands that roommate compatibility is NOT guaranteed.

Applicant represents that all of the above information is true and complete and authorizes the verification of same by reasonable means. Any misrepresentation or omission may be cause for the rejection of this application and/or the termination of the housing Agreement. Applicant further authorizes free exchange of information between Palmer College of Chiropractic and COCM, including but not limited to the applicant's student status, academic records, judicial records, and financial records.

Please be advised that incomplete, inaccurate or falsified information will be grounds for dismissal. Any individual, who may constitute a direct threat to the health and safety of an individual, the community, or the property of others, will be denied.

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am approved for residency, throughout my tenancy. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by ScreeningOne, 1860 N Avenida Republica de Cuba, Tampa, FL 33605, Phone: 888-327-6511, Fax: 888-216-1003, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

I understand that by checking the "I AGREE" box and typing my name, and clicking on the "APPLY NOW" button below, constitutes my electronic signature, dated as of when I click on the "APPLY NOW" button, and that by doing so:

• I am authorizing ScreeningOne to conduct the background check(s) described above
• I am consenting to use electronic means to sign this form and have read and understand the above disclosure
• I acknowledge I may request a hard copy of this Disclosure and Authorization form after agreeing to the background check electronically by calling ScreeningOne at Phone: 888-327-6511, Fax: 888-216-1003.

I AGREE: I, the Undersigned Applicant, have read and agree to all terms and conditions set forth in this application. I understand that this application is part of my lease, especially those areas regarding earnest monies.

The undersigned hereby offers to rent a bedroom in a unit at Palmer Student Housing under the terms and conditions described herein. The undersigned understands that apartment availability is not guaranteed and that by submitting this application as interest in a bedroom in a unit at Palmer Student Housing, the undersigned is not guaranteed a housing agreement. The undersigned understands that should a housing agreement offer be sent, he/she must complete all Housing Agreement paperwork and pay all fees to secure use of a bedroom within an apartment. The undersigned warrants that the above stated information - including but not limited to, credit and/or criminal information, employment information, and rental history - is true and correct.

APPLICANT SIGNATURE: