Housing Request Form

Please complete all sections.
You should submit an application as soon as your rotation dates are confirmed.
You will be notified if housing is available during the requested dates.
Housing for out-of-state students, students from private or non-state supported academic institutions is provided at a rate of $75/week.

If you have any questions, please feel free to call Julie Ghent at (803) 286-4121 or email her at jughent@comporium.net

Present Address
Permanent Address
_________________Rotation 1Rotation 2 (if applicable)Rotation 3 (if applicable)
Course Name and No.
Rotation Site/ Site Location/ Preceptor Name
Rotation Dates (Begin and End)
Housing Dates (Begin and End)