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_________________________________________ ___________________________________________
Street Address Street Address
_________________________________________ __________________________________________
City State Zip Code City State Zip Code
Available housing at New York University has two single beds per bedroom; therefore, you must have
a roommate. (If you do not list a roommate by April 23rd, a roommate will be randomly assigned.)
Roommate: ____________________________________________________________________________
Housing/Program fee: $2,850.00 (may be paid in three installments: March 26, April 9, and April 23)
(We accept Visa, Discover, MasterCard, Check or Cash. If paying by credit card, there will be an
additional charge of $75)
Payment by check: Make check payable to: SIUC Check #: ___________ Amount: $_____________
Payment by credit card: (If you are paying by credit card, you can pay by phone; call (618) 536-7751.)
Mail or bring form to: New York Studies, Jackie Welch, Division of Continuing Education, Washington Square,
Building C, MC 6705, Southern Illinois University, Carbondale, IL 62901
This form must be returned to Continuing Education with your payment of the housing/program fee!