OFFICE USE ONLY. Unit Size Requested Unit Number Targeted Move-In Date Date Received Time Received _C__o__k_a__t_o__P__a__r_k_v__i_e_w____________________________ _2__6_0___T__h_i_r_d__S__t_r_e__e_t__S__o__u_t_h__w__e__s_t_____________ _C__o__k_a__t_o_,__M___N___5_5__3_2__1_________________________ _P__h__:_(_3__2__0_)__9__0_5__-_2__8_7__4________________________ APPLICATION FOR OCCUPANCY Incomplete applications will be returned APPLICANT INFORMATION Applicant Name (Head of Household): First Middle Last Address: Street Address City State Zip Social Security Number: Date of Birth: [ ] Male [ ] Female [ ] Decline Applicant Phone #: Applicant Email: Alternate Phone #: Alternate Email: Emergency Contact: Name (Someone outside your household) Phone Email List All Other Household Members First MI Last Relationship to Head Date of Birth Male/Female/ Decline to Answer Social Security Number [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline [ ]M [ ]F [ ]Decline Primary Language: Do you require an interpreter? [ ] Yes [ ] No How did you hear about this housing? [ ] Online [ ] Newspaper [ ] Local Agency [ ] Drive By [ ] Resident Referral [ ] Other What is the combined gross monthly income of all household members? $ ADDITIONAL HOUSEHOLD MEMBERS CURRENT HOUSING STATUS How long have you lived at your current address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: Do all adult household members live at this address?........................................................................................................................ [ ] Yes [ ] No If NO, include additional adult household’s current address and contact information on a separate piece of paper. PREVIOUS HOUSING STATUS Your previous address: How long did you live at your previous address? From: To: Is this family or a friend? [ ] Yes [ ] No Name of Owner/Manager: Phone #: Email: Address: List every state in which each household member has lived: ELIGIBILITY INFORMATION The following questions pertain to yourself and every member of your household who will occupy the unit. Check either Yes or No in response to each question. All questions must be answered; for those questions that do not apply, you are required to indicate so by answering “not applicable” or “n/a”.
OFFICE USE ONLY. Pro Rata Amount: Date of Pro Rata Payment: Suspension End Date: Next Debit Date: Actioning Manager: Manager Signature: Date Signed: APPENDIX 3 CHANGE OF MEMBERSHIP FORM PERSONAL DETAILS First Name: Last Name: Mobile No.: Email: Home Club: New membership type requested □ Level 1 □ Level 2
OFFICE USE ONLY. Added to Financial Aid Award Approved on Student Account _ Copy scanned to Business Office
OFFICE USE ONLY. Month/year of 1st deduction: Month/year of last deduction ***Deductions must end the month after the end of the purchased membership period (i.e. Fall only = last pull 1/1; Fall/Spring = last pull 6/1). Last deductions for Annual/Summer memberships will occur on 8/1. If deduction form is received by end of business on the 10th of the month, the first deduction will be on the 1st of the next month (i.e. sold on 9/3, then deducted 10/1). If the deduction form is received after the 10th of the month, the first deduction will be on the 1st, but two months away (i.e. sold on 9/17, deducted on 11/1).*** Grand Total: $ Total # of Deductions: Amount/Deduction: $ I hereby authorize the University of North Texas Payroll Office to deduct a monthly fee from my check to pay for my Xxxx Recreation Center membership and/or locker and/or towel service. In order to cancel the deduction, I understand that I will need to contact the Recreational Sports Office (Xxxx Rec Center, Room 103) to sign the appropriate forms to stop my membership and/or locker and/or towel service. I understand that cancellation of the deduction will go into effect the month after my completing all of the necessary steps with the Recreational Sports Office. I understand that I must cancel the deduction through the Recreational Sports Office by the 10th of the month prior in order to have the deduction stopped by the next pay period. Deductions will only be taken for those months designated above. I understand, based on timing of deductions, if I cancel my payroll deduction prior to any deductions being made, I will be charged for the amount of time used up to that point. I understand and agree that if for any reason there are insufficient funds to cover the authorized deduction in any given month, then a double deduction will take place the following month and increased deductions will continue until the amount owed is paid in full.
OFFICE USE ONLY. This volunteer/intern has completed all necessary paperwork and all clearances are in order. S/he is free to serve in the following departments: Prevention Other OES Shelter/TIL Administration Support Ops Development Staff Signature Date Hours of Availability Please note: The hours you are available to complete your internship will contribute to your acceptance and assignment placement. Should your hours change after acceptance, it may affect your assignment placement and/or acceptance award. ◇ Monday ◇ Tuesday ◇ Wednesday ◇ Thursday ◇ Friday ◇ Saturday ◇ Sunday Goal(s): Please complete below only if you are applying for an internship. School: Degree being sought: Major: Internship Start Date: Internship End Date: Supervision requirements: LMSW LPC Other: Unknown Not Applicable: Hours of internship required weekly: Total hours required: Other Guidelines or Comments: (Please provide a copy of supervision/internship requirements from the school, if you are completing it for college credit.)
OFFICE USE ONLY. CCA reserves the right to suspend or discontinue any student at any time due to lack of interest, extreme absences, behavior problems, tardiness, delinquency in tuition payments, or parental noncompliance with CCA policies.
OFFICE USE ONLY. Date HTC Key Issued: Date Property Inspected:
OFFICE USE ONLY. Registration Date _________ Course _____________________ Course # ___________ **This form must be typed** STUDENT INFORMATION Name: (First, Middle I., Last) Major: CWU I.D. Number: Work Phone: Evening Phone: Cell Phone: Mailing Address during Internship: _____ _________ City: State: Country*: Zip: CWU email: SKYPE Address______________ Cumulative Credits: (Must have 45 credits to be eligible for 290; 90 credits for 490; grad student for 590 or 690) Current Cumulative GPA: Class Standing: Fresh Soph Jr Sr Post Bac Grad Quarter to Be Registered: 20 Expected Graduating Qtr/Yr: Are you an International Student with a F1 visa? Yes No International students on a F1 visa must obtain the signature of the International Student Advisor Is your internship abroad? Yes No If so- complete the Education Abroad Application. Please take this completed agreement for signature to Study Abroad & Exchange Programs located in room 101 in the International Center if the experience will take place outside of the United States. Have you signed the Student Cooperative Education/Internship Release Form? Yes No Date Have you completed the Sexual Harassment Training? Yes No Attach Certificate of Completion to this form. xxxx://xxx.xxx.xxx/student-employment/required-student-training Date Have you purchased Liability Insurance through the University? (now required) Yes No Date Insurance for non-medical settings and for medical settings. Attach proof of insurance to this form. PLACEMENT INFORMATION Employing Agency: Web URL: Internship Position Title: Business or Agency Type / Industry: Non-Profit For Profit Government Education Employer Mailing Address: (POB or Street) City: State: Zip: Country: Placement Address if Different: Site Supervisor: Title: CWU Alumnus/a Yes No On-campus supervisors for unpaid internships are required to watch Hiring an Intern video. Phone: Cell Phone: email: Work Hrs Per Week: Academic Hrs Per Week _Number of Weeks: Total Hrs: Paid _Unpaid Wage Per Hr: Other Compensation: (stipend, meals, lodging, mileage) Starting Date: (mm/dd/yyyy) Completion Date (mm/day/year) (If an internship is not completed by the grade due date an “IP” (In Progress) grade can be used. IMPORTANT: Your degree will not be awarded with an IP grade; you will have to re-apply for ...
OFFICE USE ONLY. ACH Enabled □ ACT Updated □ Scanned □ Excel Updated □ Authorization Agreement for Recurring Electronic ACH Debit Terms and Conditions 1. XXXXX affirms and certifies to, and indemnifies, XXXXXXXX that he/she is an authorized signatory on the ACCOUNT.
OFFICE USE ONLY. Entered By:
