Landlord's Name                                                   

Phone Number         
 
Landlord's Address   

Address of Facility  

Email Address  

Type of Facility 

   

Number/capacity per room, apartment, or house 
As a condition to the listing of my off campus facility(ies) with Shippensburg University, I hereby acknowledge that I will abide by applicable federal, commonwealth, and township/borough laws regarding the renting of rooms, housings, and apartments.

Print Full Landlord Name Here and Date  (This is considered your electronic signature.) Signature   Date:
  
 ____________________________________________________________________________________________________________________________________________________

Optional:  Rent Amount     Security Deposit

Is parking Available?   
 
 
Utilities Renters Pay          

 Change Requested 

  

Note: Each facility should be listed on a separate form.