Self Checkout Form
This form is for a residential student to notify the Office of Residence Life that you have all items out of your campus housing. Please check the entire room carefully and describe any issues found. You can also indicate the person responsible for the damage.
Name
*
First Name
Last Name
UE ID
*
UE Email
*
example@evansville.edu
Hall / Area
*
Hale Hall
Moore Hall
New Hall
Powell Hall
Schroeder Hall
Villages
Fraternity House
Which Village Area
*
Weinbach House
Walnut House
Jones Hall
Lincoln Park Apt
University Apt
Weinbach Apt
200 Frederick Townhouse
201 Weinbach Townhouse
315 Rotherwood Townhouse
1651 Olive Townhouse
1650 Walnut Townhouse
1660 Walnut Townhouse
Which Fraternity House
*
FIJI
Phi Kappa Tau
Tau Kappa Epsilon
Unit
*
Room
*
Any issues with the paint? Note specific location and issue.
(scratches, dents, holes, cracks, paint chips, bad paint, dirt, etc.)
Upload a picture of any paint issues.
Browse Files
Cancel
of
Person responsible for any paint damage.
First Name
Last Name
Any issues with the flooring? Note specific location and issue.
(stains, rips, holes, etc.)
Upload a picture of any flooring issue.
Browse Files
Cancel
of
Person responsible for any flooring damage.
First Name
Last Name
Any issues with your furniture (bed frame, mattress, desk, desk chair, dresser, closet, etc.)? Note specific location and issue.
(scratches, rips, stains, damage, etc.)
Upload a picture of any furniture damage.
Browse Files
Cancel
of
Person responsible for any furniture damage.
First Name
Last Name
Any other issues (windows, screens, lights, door, door handle, lock, outlets, etc.)? Note specific location and issue.
(broken, cracked, torn, needs tightening, damaged, etc.)
Upload a picture of any other issues.
Browse Files
Cancel
of
Person responsible for any other damage.
First Name
Last Name
Resident Signature - I verify that the furniture has been returned to the original room configuration and all of my personal items have been removed from this room. I understand Residence Life Staff will check for additional damage later which could result in potential fees.
*
Submit
Should be Empty: