Housing Application Form

Thank you for your interest in the Washington Internship Institute’s student housing.Please save this form to your computer, type your responses,print the form, and sign your name at the bottom. Applications without a signature will not be accepted. Please either scan and email this form and the housing regulations to or mail them to Washington Internship Institute,1015 18th St. NW, Suite 1101,Washington,DC20036. If mailing the forms, please include a check payable to Washington Internship Institute for $130. If faxing or emailing the forms, please call the WII office at (800) 435-0770 for payment instructions.

Personal Data
Last name
First name
Middle initial
Preferred name (if different)
Gender
Current Address /
Current Address
City / State / Zip
Current Phone / Current Email
Address Current Until(mm/dd/yy)
Country of Citizenship
Permanent Address
Permanent Address
City / State / Zip
Permanent Phone
Date of Birth (mm/dd/yy)
School
Year in School
Advisor’s Name
Advisor’s Phone Number
Advisor’s Email
Program Affiliation
Applying for / Fall 2014
Requested Move-In Date(mm/dd/yy) / Requested Move-Out Date (mm/dd/yy)
Note: These dates are subject to WII’s approval.
Internship Information
Internship Site
Supervisor’s Phone Number

Emergency Information

Emergency Contact Person
Relationship
Address
City / State / Zip
Day Phone / Evening Phone
Health Insurance Company
Address
City / State / Zip
Phone
Policy Number
Group Number
Note: Please provide any pertinent information on disabilities, medical conditions, ormedications. Use a
separate sheet if needed.

Housing Policy
A $100.00 housing depositand $30 fee for a background check are required. The student is responsible for all fees. Full payment of all fees is due 14 days prior to arrival. All cancellations must be received in writing. There is a $130.00 cancellation fee. There are no refunds on or after the 14 days prior to arrival.

If you choose to live in WII’s housing, you must accept the following rules and regulations:

  • WII does not assume responsibility for personal property and suggests that you insure your valuables.
  • No smoking is permitted. Students must go outside to smoke.
  • No pets are permitted on the premises.
  • WII reserves the right to change the students’ accommodations at any time, fill a vacancy by placing another person in the room without prior notice, and enter the room if needed.
  • WII reserves the right to terminate the housing agreement for any irresponsible conduct, unpaid fees, or conduct which is harmful or potentially harmful to self or others.
  • WII assumes no liability.
  • Housing is contingent on successful completion of a background check.

I certify that I have health insurance. I have read and understand the housing policies. I understand the housing fee will be payable 14 days prior to my arrival. The information I have provided is complete and accurate.

Signature ______Date ______

Please mail signed application, signed housing regulations, and $130 (check or money orderpayable to Washington Internship Institute)to:

Washington Internship Institute

1015 18th St., NW, Suite 1101

Washington,DC20036

(202) 833-8580 phone

(800) 435-0770 toll-free

(202) 833-8581 fax