Online Housing Application

If you will be living in housing at PNW and will need an accommodation due to a disability, please fill out this application in it's entirety.

If you will also need accommodations in your course's at PNW, please also fill out the accommodation request form online.

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Primary Campus *:
Note: Please select campus location where you will be enrolled.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID:
Hint: Enter 9 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender *:
Pronouns:

Contact Information

Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address *:

Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Permanent Address Same as Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Additional Information

Campus Location(s)

Hammond

Westville
Additional Note:

Questions

Please provide additional information that you feel may be helpful in determining your accommodations.
Are there any additional housing accommodations that may be helpful?

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Code	Description
OFR	Online Fully Remote
VC	Virtual Classroom: Live LEC
HYB	Hybrid: On-Campus + Online
FTF	Face-to-Face: In-Person

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PNW Accessibility Center - Purdue University Northwest