University Housing & Dining Services Housing Petition

University Housing & Dining Services Housing Petition

Western Illinois University
I am petitioning*

To live off campusTo have my contract breakage fee waivedTo request a meal plan variance
STUDENT ID # (XXX-XX-XXXX)*
BIRTH DATE (MM-DD-YYYY)*

MonthDayYear
Date
PHONE (XXX-XXX-XXX)*
Email*
example@wiu.edu.com
Full Name*

FIRST NAMEMiddle NameLAST NAME
Current Residence Hall Assignment (Include Hall & Room #) Or Local Address*

Street Address Line 2

CITYState / Province

Postal / Zip Code
ST*
ZIP*
Permanent Home Address*

Street Address Line 2

CITYState / Province

Postal / Zip Code
ST*
ZIP*
Proposed Address If Release Granted*

Street Address Line 2

CITYState / Province

Postal / Zip Code
ST*
ZIP*

Please state clearly your reason(s) for requesting exemption to or release from the Western Illinois University On-Campus Housing Policy?*
STUDENT SIGNATURE*

Clear
Date*

MonthDayYear
Date
Parent/Legal Guardian Statement
Only required for commuter students requesting to live with parent or legal guardian.
PARENT OR LEGAL GUARDIAN SIGNATURE

Clear
Date

MonthDayYear
Date
Please upload any supporting documents.

Cancelof
Western Illinois University,

University Housing & Dining Services, 1 University Circle, Seal Hall, Macomb, IL 61455

(309)298-2122

UHDS@wiu.edu
For Office Use Only

This section will not be visible to form submitters.
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Housing AdministrationFormsUHDS-HousingPetition-3.28.24
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For Office Use Only