I. Room Lottery Choosing Number  * If you are unsure about your number please use zero and the Residential Life Office will look this up for you at a later date. 

2. Name
First *
Last *  

3. CID Number * - located on your MHC id card. 

4. Class Year *

5. Mount Holyoke Email (ex: lyon22m@mtholyoke.edu) *

6. Phone number *
Cell Extension

7. Current fall 2009 housing assignment * Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder
Room number Room type Choose one Single Double Triple Quad Suite

8. Purpose of room change request *

2. My roommate(s) is/are aware of this request.

3. The name of the first student I would like to live with next semester is
Class Email
This student is aware of this request Yes No

4. The name of the second student I would like to live with next semester is
Class Email
This student is aware of this request Yes No

Preference 1:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 2:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 3:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 4:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 5:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 6:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 7:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 8:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 9:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

Preference 10:
Choose one Not applicable 3 Park Street 17 Morgan Street 24 Silver Street 57B College Street 1837 Abbey Brigham Buckland Dickinson Ham MacGregor Mead North Mandelle South Mandelle North New Hall South New Hall Pearsons Pearsons annex Porter Prospect North Rockefeller South Rockefeller Safford Torrey Wilder Floor Basement* First Second Third Fourth Fifth Sixth Room Type Single Double Triple Quad Suite

2. More preferences:

3. Do you smoke? *
Yes No

4. Would you live in a basement room? *
Yes No

5. Would you live on a quiet floor? (3rd floors of Abbey & N. Mandelle) *
Yes No

6. Are you willing to move ANYWHERE (including basement/Mezz/quiet floor) to get a single? *
Yes No

• I have read and understood the directions for requesting housing or a room change.
• I have read and understood that there is no guarantee my top choices are available.
• If my preferred choice(s) is not available when making a room change request, I will remain in my current assignment.
• Filing a room change request is not a guarantee that you will be moved.
• If applying for a room change, I will pack and clear my belongings from my room if not on campus for the first week of January tem in accordance with the directions on this form or my request will be voided. 
• If filing a housing request, I understand that I may not be able to live on campus during January term in my spring 2010 assignment and will make alternate arrangements to live with a friend until my assignment is ready. 
• In accordance with the Honor Code, submission of this form verifies that I have told my roommate (if applicable) that I am requesting a move. Falsification of this form or misrepresentation of information will warrant an Honor Code violation. Residential Life staff members are available to help with these conversations if needed.
• The Office of Residential Life does not assume the responsibility of informing roommates about room change requests. If a change occurs as a result of your request, it is your responsibility to inform your roommate.

I have read and I agree with the above statements. *

Today's date: Select Month January February March April May June July August September October November December * Select Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * Year: *

If you have any questions before submitting this form please feel free to contact the Office of Residential Life at 413-538-2088.