SUNY Urban Teacher Education Center (SUTEC)  
Parkchester Housing Placement Request


Directions:  Please complete this application and attach your $300 security deposit. Security deposit check 
		or money order must be made payable to The Research Foundation of SUNY. 


I. Personal Data:

	Last Name: ______________________________   First Name: ___________________________


	SUNY College/University: ____________________   Social Security #: _____________________


	Gender:	Male___     Female___


	Expected Graduation:  Month _____   Year _____


	Campus Address: _________________________________________________________________


	Campus Phone: ________________   E-Mail Address: ____________________________________


	Permanent Address: _______________________________________________________________


	Permanent Phone: _________________   Student Teaching Term:  Fall ___  Spring ___   Year____


II. Do you have a specific roommate you would like to live with:  0 yes	0 No

	If you answered "yes" to the above question, please provide your roommate's information below
   
	Last Name: _________________________________   First Name: ____________________________

	SUNY College/University _____________________  


III. Return completed application to:  

	SUNY Urban Teacher Education Center		Tel:  718.802.3337				
	111 Livingston St., Suite 400			Fax:  718.802.3395			
	Brooklyn, NY 11201
	Attention: Regina Anderson