First Name:    Last Name:    Title:

Address:

City:    State:    Zip code:

Country:

Home Phone:    Business Phone:

Fax:    E-mail

UCAR/NCAR Division you will be working with:

The name of your UCAR or NCAR contact person:

Your gender:   Male   Female

Your age range:   18-25   26-36   37-47   48+

Marital Status:  Married Single

Spouse name if accompanying:

Total number of people who will be occupying the property:

Ages of children:    Pets (describe):

Does anyone in your household have allergies that would affect housing placement?
Please describe:

Will you have a car? Yes No

Does anyone in your household smoke? Yes No

Dates you will need housing:   Arriving:      Departing: 

Length of your stay:   

Before completing the rest of this form, you must check the Rent Rates page.

Maximum monthly rent you can pay in US dollars:   $

Housing Preferences I (check all that apply):
    Hotel Room
    Room in private home
    Apartment/condo
    Apartment in private home
    Townhouse
    House

Housing Preferences II (check all that apply):
    Furnished
    Partially furnished
    Unfurnished
    Any

Number of bedrooms you require:    Number of bathrooms you require:

Other Preferences or Comments: