UCHA Application Form

Instructions:

Step 1 - Please fill-out the under mentioned information which will automatically be transferred into the official application form. Double check your information for accuracy before submitting Please also note the following:
- Fields marked with an asterisk (*) are required.
- Social Security # is required only if the Country of Birth or Citizenship is United States (USA).
Step 2 - Please print the PDF form, sign and date in all places where it states 'Signature and Date' before sending it to the UCHA.
Step 3 - Fax: 1-310-824-0112 or Email application to: admissions@ucha.coop attached with clear copies of the following:
- 1) Proof of student status, 2) a state ID/passport copy and 3) application fee ($35) / express fee ($60) payment.
- Bring additional documents to check in.

Please contact for technical problems

* Quarter Applying For

Fall Winter Spring Summer

* Personal Title

Mr. Ms. Other

* First Name

* Last Name

* Date of Birth

* Country of Birth

* Country of Citizenship

* Mailing Address

* Email

* Phone

Cell

Fax

* Social Security #

Passport #

Driver's License #

* When would you like to move in?

* Are you a full-time student?

Yes No

* College you will attend

UCLA Undergraduate UCLA Graduate UCLA EAP UCLA Research UCLA Staff
UCLA Visiting Scholar UCLA Extension SMC Other

* Degree/Major/Certificate Program of study

Student Id #

Father's Name

Mother's Name

Address

Contact Phone: Home

Contact Phone: Work

Previous landlords in whose apartments you have lived within the last 3 years. Do not list relatives.

Reference 1

Reference 2

* Name(s)

* Relationship

* Address

* Phone: Home

Phone: Work

* How did you learn about UCHA?

Bruin Ad Mailing Campus Posting Friend Other
Current Co-oper If Current Co-oper: What is their name / deposit number?

* What does cooperative living mean to you?

* Have you ever been convicted of a felony or misdemeanor?

No Yes

* Have you lived here before?

No Yes Were you expelled/Evicted?

* Have you applied to UCHA before (for housing)?

No Yes

* Have you been evicted by a previous landlord?

No Yes

* Do you need disability accommodations?

No Yes If you anser Yes, click here to download Disability Accommodations Request form

Visa/MasterCard #

Amount

Expiry

Security Code

Zip Code

Please ensure that you manually sign and date the Application Form (where it states 'Signature and Date'), before sending to the UCHA. If payment is made by credit card then sign and date in the required section as well.

UCHA Application Form

Application Form

Personal Info:

Parents:

References:

Emergency Contact:

Other Info:

Disability Accommodations:

Payment Authorization: