JLLC Application

Thank you for your interest in applying to live at the Dr. Maxwell H. Goldberg Jewish Living and Learning Community at the University of Massachusetts Hillel. Please fill out this form below.

Personal Information

Full name: *

Please enter your full name.

Sex: *

Please select your sex.

Phone Number: *

Please enter a phone number where you can be reached.

E-mail address: *

Please enter your e-mail address.

Telephone number

Phone number where you can be reached

College: *

Please select your college

Year of Graduation: *

Major: *

Please enter your major.

Student ID number:

Enter your student ID number (eight digits for UMass students).

Date of Birth: *

Residency Options

Period of residency: *

Please write your desired period of residency: Winter Session '09, Spring '09, Summer '09, or Fall '09,

Single or double occupancy: *

Please select your desired room type.

Address information

School address: *

Please enter your school address, city, state and ZIP code.

Permanent address: *

Please enter your permanent address, city, state and ZIP code.

Parent information

Parents' names:

Please enter your parents' names.

Parking information

Make:

Please enter your automobile make.

Model:

Please enter your automobile model.

Model year:

Please enter your automobile model year.

Plate number:

Please enter your automobile plate number

State of registration:

Please enter the state of registration of your automobile.

Owner:

Please enter the owner of your automobile.

Other information

Preferred roommate:

Please enter the name of the person with whom you would prefer to share your room (if selecting double-occupancy above).

Previous Jewish-related activities:

Fall/Spring applicants only.

Previous roles and honors:

Fall/Spring applicants only.

How did you hear about the JLLC? If from a current JLLC resident, please give us his/her name.:

Provide name and contact number for your last landlord or RA.:

Former landlord or RA

Captcha

This question is used to make sure you are a human visitor and to prevent spam submissions.

What code is in the image?: *

Copy the characters (respecting upper/lower case) from the image.

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JLLC Application