Room Change Request Form Page 2
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1
2APPLICANT INFORMATION
Name: _____________________________________ Student ID #:_____________________________
Email: _____________________________________ Cell Phone #: ____________________________
Current Building and Room: __________________ Building Preference: _____________________
Signature: ______________________________________________
COMMUNICATION WITH CURRENT ROOMMATE(S)
In the space provided below, please identify the reasons for which you are requesting a room change. These
reasons must be discussed with your current roommate(s). If the reasons are a result of difficulties within the
room, you must communicate these issues with your roommate(s).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Roommate Name(s): Printing and signing your name(s) means that you have discussed as a room the reasons
outlined above for why a room change has been requested.
1. Name: ____________________________________ Signature:______________________
2. Name: ____________________________________ Signature: _____________________
3. Name: ____________________________________ Signature: _____________________
4. Name: ____________________________________ Signature: _____________________
5. Name: ____________________________________ Signature: _____________________
ROOMMATE CONVERSATION WITH RA
Date of mediation: _______________________
Time: ________________
-Discuss Roommate Contract
-Discuss Concerns:
__________________________________________________________________________________________
________________________________________________________________________________
Create action steps for resolution:
__________________________________________________________________________________________
________________________________________________________________________________
Were all roommates present for this conversation? Yes or No
RA name: _________________________________
Signature: ___________________
RA recommendation for room change: Yes or No
RA comments:
_____________________________________________________________________________
CURRENT RESIDENCE DIRECTOR RECOMMENDATION
This room change request has been:
Approved
Denied
Comments: ___________________________________________________________________________
Signature: ___________________________________________ Date: _______________________
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