Housing Cancellation Form - Messiah University

1. Date of request (Today's date):

2. Student ID #: Required

3. Student Last Name: Required

4. First Name: Required

5. Email Address: Required

6. Phone Number:

7. Housing Assignment Hall/Apt.: Required

8. Room #: Required

9. Check-out Date (if you are staying until the end of the semester and don't know what date you'll be leaving, just choose the last day of the semester): Required

10. Leaving:

During the Semester End of Fall End of Spring

11. Reason(s) for Cancellation - mark all that apply: Required

12. (Please explain)