Please fill out all fields of this form to the best of your knowledge. If you should have any problems or questions filling out this form, please contact the Coordinator at 314.516.4399. All intern housing request forms must be received by May 1, 2015.

Fields denoted with an asterisk (*) are required.

Personal Information
*Intern's Name:
*Gender:
*Mailing Address:
*City:
*State:
*Zip Code:
*Daytime Phone:
*Evening/Mobile Phone:
*E-Mail Address:
Internship Information
*Name of Company:
*Company Contact:
*Contact's Email:
*Contact's Phone No.:
Accomondations
*Arrival Date (MM/DD/YR):
*Arrival Time (AM or PM):

Arriving by:

Vehicle
Air
*Departure Date (MM/DD/YR):
*Departure Time (AM or PM):

*Will you be bringing your own bed and bath linens or
Will you need Guest Housing to provide them for you?

Note: All mattresses are XL Twin.

Please provide the following item(s) for my stay:

Emergency Contact Information
*Primacy Contact's Name:
*Relationship:
*Main Phone:
*E-Mail Address:
*Secondary Contact's Name:
*Relationship:
*Main Phone:
*E-Mail Address:
Vehicle Information *Please note that all vehicles parked on the University of Missouri-St. Louis campus are required to display valid parking permits.*

*Will you need to park a vehicle on campus?
Note: Parking is charged at the rate of $1 per day.

Yes
No
Vehicle Make:
Vehicle Model:
License Plate Number:
State in which vehicle is licensed:
Roommate Selection
Do you have any roommate preferences?
All rooms are single private sleeping rooms within a four room single gender suite. Due to limited space, Conference and Event Services is unable to guarantee your requests, but all efforts will be made to honor them.
Roommate 1 - Name:
Roommate 2 - Name:
Roommate 3 - Name:

Would you like the phone and data ports activated during your or your guest's stay?

*Please note that the charge is an additional $12.50/week (there is no daily rate and the ports are bundled).

Yes
No

Will you need a guest wireless account created for you during your stay? (There is no charge.)

Yes
No