University Housing & Dining Services | Request for Contract Cancellation

University Housing & Dining Services | Request for Contract Cancellation
STUDENT ID # (XXX-XX-XXXX)
BIRTH DATE (MM-DD-YYYY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ROOM/HALL ASSIGNMENT TO BE CANCELED
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MARK APPROPRIATE BOX - ALL REASONS MUST BE VERIFIED BY OUR OFFICE.
Reason for cancellation

Other
SEMESTER(S) TO BE CANCELED
Years of Semesters to be Canceled
Years of Semesters to be Canceled
CHECKOUT DATE (WITH YOUR RA OR HALL STAFF)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Per residence hall contract Terms and Conditions, residence hall contracts are legal and binding for the academic year for students that remain enrolled at the University. If the condition indicated above for contract cancellation should change, please note that this does not negate the agreement and responsibility to reside on campus. Room and board charges will be assessed accordingly. Upon verification, students withdrawing from the University or participating in a University class or internship away from the Macomb campus may be exempt from a contract breakage fee. For more information, please refer to Section VIII of your residence hall contract. The undersigned hereby requests cancellation of the University residence hall contract to be effective as of the date indicated on your completed Room Condition Report and for the reason indicated above.
STUDENT SIGNATURE (DOCUMENTATION IF NO SIGNATURE)
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IMPORTANT INFORMATION
Vacating Residence Hall: If residing in a residence hall, you must follow each step below with a residence hall staff member before your contract will be canceled.
1. Complete and sign your Room Condition Report.
2. Turn in your room key.
3. Please confirm your forwarding and billing addresses on STARS.
University withdrawal: You must go to the Student Development Office to withdraw from classes — University Union, 1st Floor
For office use only
Reapplication must be on file. Accepted by
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Registration Status
Verified by
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Work Processed
Initials
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assignments
Meal Plans
Comments:
Canceled
Transferred to GFH Office
Contract Breakage Fee by predetermined schedule/contact UHDS
Contract # $
MicroFridge
White-UHDS
Yellow-Student
Please the year of the term to be canceled
Should be Empty:

University Housing & Dining Services | Request for Contract Cancellation

MARK APPROPRIATE BOX - ALL REASONS MUST BE VERIFIED BY OUR OFFICE.

IMPORTANT INFORMATION

For office use only