OFF CAMPUS STUDENT SERVICES INTAKE FORM "*" indicates required fields Step 1 of 2 - Let 50% Name * Required First Last UIN * RequiredClassification * RequiredPick one...FreshmanSophomoreJuniorSeniorGraduate Student- MastersGraduate Student- PhD or Terminal DegreeCurrent Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required Please indicate your reason(s) for seeking support from Off Campus Student Services. * Required Housing Search Assistance Leasing Questions Maintenance Issues Landlord Conflict Roommate Conflict Neighbor Conflict Financial Difficulty Health/Safety Concern Legal Issue Other Please briefly describe the situation you would like to discuss with an Off Campus Student Services team member. * RequiredHave you attempted to address the situation? * Required Yes No What steps have you already taken to try to address the issue?How soon do you hope to resolve this issue? * Required Within 1-2 days Within the week Within 1-2 weeks Within the month Other Please upload any relevant documentsMax. file size: 50 MB.How did you hear about us? * RequiredCAPTCHA
