TEXAS WESLEYAN UNIVERSITY

HOUSING & DINING APPLICATION

Whiteside Kevin Joseph 0292963
NAME____________________________________________________________________________ Student ID# ________________
LAST FIRST MIDDLE
5617 Whitley Rd
PERMANENT ADDRESS__________________________________________________ 817 428 7230
PHONE____________________________H
N/A
________________________________________________________________________ ____________________________W
Haltom City Texas 76148 817 896 1189
CITY____________________STATE___________________________ZIP___________ ____________________________C

kjwhiteside@mail.txwes.edu
UNIVERSITY E-MAIL____________________________________________________ 07 01 1988
DATE OF BIRTH_____/_____/______
inblessedsilencewaiting@gmail.com
ALTERNATE E-MAIL_____________________________________________________

x Undergraduate x Freshmen Sophomore Junior Senior

Graduate First Year Second Year Third Year

Transfer Mathematics
Major : ____________________ __
International Student
Other/Please Indicate ___________________

Are you a Student Athlete YES x NO Sport ________________ Room Grant Recipient YES NO

Beginning on January 1, 2010, incoming students who live on campus will be required to provide either evidence of vaccination against
bacterial meningitis or a signed affidavit declining the vaccination prior to living on campus. Students will not receive a housing assign-
ment until one of these two documents is received by Texas Wesleyan Residence Life Department 10 days Prior to moving in. For more
information regarding the new House Bill 4189 please contact the Housing office at 817-413-5000.

Instructions:

1. Submit your completed housing application along with a $25 Non-Refundable application fee and a $200 Refundable Security Deposit to
the Housing Office. The security deposit is refundable per the Cancellation Policy below.
2. Turn in a Bacterial Meningitis Shot Record (Must be signed and dated by a Health Professional, and received by the Housing Office 10
days prior to move-in..

Fall Semester
-Cancel on or before May 1 100% of Deposit is Refundable
-Cancel May 2 - July 1 50% of Deposit is Refundable
-Cancel After July 1 Deposit is Forfeited

Spring Semester
-Cancel on or before November 1 100% of Deposit is Refundable
-Cancel November 2-November 30 50% of Deposit is Refundable
-Cancel after November 30 Deposit is Forfeited

THE ACCEPTANCE OF THIS APPLICATION DOES NOT ENSURE AN ACCOMODATION. AN ACCOMMODATION IS RESERVED
ONLY UPON COMPLETION OF A COMPLETED APPLICATION/DEPOSIT, MENNIGITIS RECORD, AND ADMITTANCE INTO THE
UNIVERSITY. PRICES ARE SUBJECT TO CHANGE

It is the students’ responsibility to familiarize themselves with all of the provisions of the contract, as this is a binding
contract and will be enforced once signed. I hereby agree that I have read and will abide by all the terms of the contract.
_________________
Kevin Whiteside ____________________ ___________________
07/17/2010
PRINT NAME SIGNATURE DATE
Office use only

Room Assignment_____________________________ Billing Type____________________ Date Entered in Datatel_____/______/______

 EMERGENCY CONTACT INFORMATION

Name____________________________
Jonna Whiteside Relationship_____________________
Mother

Address__________________________________________________________
5617 Whitley Rd Haltom
CityStreet TX City State
Zip
Phone Number (c)_________________________
817 966 5602 (h) _____________________(w)
817 428 7230 _________________________
817 820 7026

tjsk99@hotmail.com
E-Mail Address _________________________

In the event of an emergency, does this person have permission to gain access to your room/apartment to retrieve your
items?
X
Yes No

PARKING/VEHICLE INFORMATION
Vehicle Make:_____________________________________ Model/Color:__________________________________

License Plate Number:______________________________ Year:__________________________________

MEAL PLANS
Undergraduate students are required to purchase residential meal plans. If you are required to have a meal plan and do not select a plan, the Plati-
num meal plan will automatically be chosen for you. All meal plans are the same price.

x PLATINUM - Unlimited Meals per week at Dora’s Restaurant plus $50 Declining Balance per semester

For those who like 3 or more meals per day and like to come and go as they please, this offers you unlimited access to our all-you-care-to eat
facility during breakfast, lunch, dinner, plus all the snack periods in between during regular hours of operation. Plus, you’ll receive $50 Declining
to use for spending at Java City, The Grille, and The Convenience Store.

GOLD - 15 Meals per week plus $100 Declining Balance per semester

Ideal for those likely to eat 15 all-you-care-to-eat meals weekly. The plan is supplemented with $100 Declining Balance to use for spending at
Java City, The Grille, and The Convenience Store.

SILVER– 12 Meals per week plus $150 Declining Balance per semester

Designed for those likely to eat 12 all-you-care-to-eat meals per week, plus $150 Declining Balance for spending at Java City, The Grille, and
The Convenience Store.

NONE - Graduate students are not required to purchase a meal plan.

ADDITIONAL DECLINING BALANCE DOLLARS

Students may elect to put an additional amount of Declining Dollars on their cards. If you would like to do so, please tell us how much.
$___________

Kevin Whiteside
______________________________________ ________________________________________ 07/17/2010
__________________
Printed Name Signature Date
 CONTRACT LENGTH
Please check the term (s) in which you are applying for and indicate the year.

SUMMER 1 ________ SUMMER 2 ________ x ACADEMIC YEAR _________

2010 Fall Short Term _________ Spring Short Term_________

Select this option if you are a December Graduate or Nurse Anesthesia Student staying for the Fall Only_________.

SPRING ONLY__________

HOUSING PREFERENCES
Housing Preferences will be honored on a first come, first serve basis according to the date your completed Application
is received.

RESIDENTIAL FACILITIES
(Please rank your preferences from 1-4, with 1 being your favorite and 4 being your lease favorite)

Upper Classmen Traditional Hall Undergraduate Traditional Hall Wesleyan Village Apartment Style
2 1 3
_____Elizabeth Hall Single ______Stella Hall Double ______Single in a 4-Bedroom

4 Single Efficiency
______

Please see page rate schedule

ROOMMATE REQUESTS
Room and roommate assignments are subject to change prior to occupancy. All attempts will be made to inform you of these in a
timely manner. Request are guaranteed if all roommates are in agreement. Requests must be received in writing by June 30th.
If a roommate is not chosen then one will be assigned by the Housing Office.
To ensure accuracy, please use the Legal First and Last name of the person you are requesting.
Johnathon Smith
1)______________________________ 2)______________________________ 3)_______________________________

O
Please circle the best answer that describes what you are looking for in a roommate.

O
Do you Smoke? Yes No
Do you mind if your roommate smokes? Yes No

Please note, smoking inside the residence halls is prohibited.

O
If you are in a Greek Organization please state which one? ________________________

O
Are you organized? Yes No
Are you a morning person? Yes No

O
O
I see myself studying Daily Occasionally (2-3 times a week) Seldom (2-3 month) Never

O
I like to study in the Morning Afternoon Evening Late Night
I like my room clean Extremely Clean Somewhat Messy Very Messy I don’t care
I am involved in activities Extremely Involved
Is there anything you want to add to help us assign you a roommate?
Involved
O
Seldom Involved Never

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________

IT IS THE POLICY OF THE UNIVERSITY TO ASSIGN ROOMMATES WITHOUT REGARD TO AGE, RACE, SEX, CREED, RE-
LIGION, DISABILITY, OR NATIONALITY.
Housing Check List

□ Submit Contract/Application
Initial Each Page
Keep a copy for your records
Send to: Residence Life Department
1201 Wesleyan St.
Fort Worth TX 76105
□ Submit $25 non-refundable application fee and $200 refundable housing deposit
Payment can be sent with contract by check or money order (no cash) to the above address, paid to the
cashier’s office directly or submitted online at our website: http://www.txwes.edu/residencelife/
howtoapply.htm

Roommate Requests:
Roommate requests must be mutual. Correctly completed roommate requests will be honored if received
by the housing office on or before June 30th.

Room Assignments:
Specific room assignments will not be given until the first day of move in. If possible, roommate assignments
will be sent out the first week in August.

2010-2011 Room Rates * Stella, Elizabeth hall will be

closed for the summer. Resi-
dents of those buildings who
WESLEYAN VILLAGE
wish to reside on campus dur-
Efficiency Single Occupancy
ing the summer will be given
**Summer 1 **Summer2 Fall Spring
this special rate to live in a
$865 $865 $4,325 $4,325
single in a four bedroom
Wesleyan Village Apartment.
Four Bedroom
TO QUALIFY, THE STUDENT
**Summer 1 **Summer 2 Fall Spring
MUST LIVE ON CAMPUS
$405 $405 $2,025 $2,025
FOR THE ENTIRE SUMMER
AND REGISTER TO LIVE IN
STELLA/ELIZABETH HALLS
EITHER STELLA OR ELIZA-
Double
BETH IN FALL. If a student
**Summer Fall Spring
applies for this special rate
$624* $1560 $1560
but later decides to stay in
Wesleyan Village, or stays
Single
one summer session, a ret-
Fall Spring
roactive fee increase will be
$2,340 $2,340
applied to the student’s bill.
MEAL PLAN RATES

$1,430 + Tax (ALL)

Platinum: Unlimited meals per week plus 50 Declining Balance Dollars per semester
Gold: 15 meals per week plus 100 Declining Balance Dollars per semester
Silver: 12 meals per week plus 150 Declining Balance Dollars per semester