Student Information

	Last Name
	First Name
	Middle Initial
	Social Security Number
	Gender		Selectmalefemale
	Birthdate [mm/dd/yyyy]
	Former High School
	Major
	Study Habits		Morning Afternoon Evening Late Night
	Hobbies/Activities		Sports Fitness Current Events Music Socializing
	How Did You Hear About Bromley?		Select Family/Friend Current Resident Certified Housing Website University of Illinois Mailing Internet Search Engine High School Other

Student Address

	Home Street Address
	City
	State or Province
	ZIP/Postal Code
	Home Phone Number
	Cell Number

Parent / Emergency Information

	Parent Last Name
	Parent First Name
	Parent Social Security Number
	Parent Home Phone
	Parent Emergency Phone
	Parent Email Address
	Emergency Relationship		SelectParentGuardian

Residential Data

	Requested Room & Board Type (includes local sales taxes)
	Single Room w/ All Meals Served ($14,128) Double Room w/ All Meals Served ($11,160) Triple Room w/ All Meals Served ($9,840) Deluxe Double Room w/ All Meals Served ($12,640) Corner Deluxe Double Room w/ All Meals Served ($12,028) Quad Room with All Meals Served ($8,908) ----------------------------------------------------- Single Room w/ Any 2 Meals Per Day ($13,880) Double Room w/ Any 2 Meals Per Day ($10,912) Triple Room w/ Any 2 Meals Per Day ($9,592) Deluxe Double Room w/ Any 2 Meals Per Day ($12,392) Corner Deluxe Double Room w/ Any 2 Meals Per Day ($11,780) Quad Room w/ Any 2 Meals Per Day ($8,660) ----------------------------------------------------- Price includes applicable local sales taxes.
	Alternate Room & Board Type (includes local sales taxes)
	Single Room w/ All Meals Served ($14,128) Double Room w/ All Meals Served ($11,160) Triple Room w/ All Meals Served ($9,840) Deluxe Double Room w/ All Meals Served ($12,640) Corner Deluxe Double Room w/ All Meals Served ($12,028) Quad Room w/ All Meals Served ($8,908) ----------------------------------------------------- Single Room w/ Any 2 Meals Per Day ($13,880) Double Room w/ Any 2 Meals Per Day ($10,912) Triple Room w/ Any 2 Meals Per Day ($9,592) Deluxe Double Room w/ Any 2 Meals Per Day ($12,392) Corner Deluxe Double Room w/ Any 2 Meals Per Day ($11,780) Quad Room w/ Any 2 Meals Per Day ($8,660) ----------------------------------------------------- Price includes applicable local sales taxes.
	University/College Attending		University of Illinois
	Year in College		freshman sophomore junior senior graduate level
	Previous Housing		new student on campus returning resident transfer student
	Student Computer Type		none windows macintosh
	Student Email Address
	Billing Email Address
	UID Number (if unknown, leave "0")

Roommate/Suitemate Request

If you wish to be roommates or suitemates with certain people please indicate that in this section. Bromley Hall will only honor mutual roommate and/or suitemate requests. The other person(s) with whom you would like to live must also request you as a roommate or suitemate in his or her Room and Board Agreement Addendum. Room assignments are made on a first-come-first-served basis.

	Roommate 1 Request
	Roommate 2 Request
	Suitemate 1 Request
	Suitemate 2 Request
	Suitemate 3 Request

Down Payment/Credit Card Information

Bromley Hall requires prospective residents to pay $350 when submitting their application. $300 will be applied to your account as a security deposit, and $50 is a non-refundable processing fee.

	Credit Card Type		Visa Mastercard
	Credit Card Number
	Expiration Date [mm/yyyy]
	CVN (What is this?)
	Cardholder Name
	Cardholder Address
	Cardholder City
	Cardholder State/Province
	Cardholder ZIP/Postal Code

I hereby acknowledge that I have received, read, understand, and agree to the terms and conditions contained in the Bromley Hall Room and Board Agreement. I agree to be bound to the Room and Board Agreement terms and rates for the 2012/2013 Academic Year as indicated on the Room and Board Agreement Addendum. FOR VALUE RECEIVED, and in consideration for, and as inducement to The Bromley Group of Companies, Inc, as the AGENT for Bromley Hall, making the foregoing Agreement, the undersigned guarantees to the AGENT full payment and performance by the STUDENT of his or her obligations under the Agreement without requiring notice of non-payment, non-performance, or proof of notice or demand, all of which the undersigned expressly waives, and the undersigned expressly consents to any modifications of the Agreement, including but not limited to extensions of the term of the Agreement and adjustments to the room and board rates contained in the Agreement, and any extensions of time or indulgences granted by the AGENT to the STUDENT. I HAVE READ AND UNDERSTAND THE REFUND AND LIABILITY PROVISIONS CONTAINED IN THE AGREEMENT. I hereby authorize my electronic signature as submitted herewith to be as valid and binding as my original signature.

Check this box to indicate your acceptance of the above statements.

Thank you for your interest in Bromley Hall at the University of Illinois. After you click on the submit button, your down payment will be processed and your completed application will be processed as soon as possible.