MONTEFIORE MEDICAL CENTER
APPLICATION FOR HOUSING (House Staff)
Applicant Information
First Name Last Name  
SS # Contract  
If you do not have a social security number, please type "0". Contract Start Date  
Email Address Confirm Email Address
Please note that all status updates will be made via email. Please be sure to use an address that you will have access to through July.
       
Department          
Is your contract with Montefiore’s Wakefield Campus? Yes No
Are you a current AECOM student? Yes No
Do you have a social security number? Yes No
Medical School  
How long is your Montefiore training program (Years)  
Have you matched into the department of surgery - transplant program? Yes No
Did you couples match? (if yes, please only submit one application per household) Yes No
Do you currently reside in the United States? Yes No    
Current USA Address
Street Apt Number    
City State Zip Country
Cell Phone Alternate Phone        
Current International Address
International Address
Family Composition
(Please list anyone who will be residing with you in Montefiore Housing)
Name Relationship Marital Yes No Gender M F
Name Relationship Marital Yes No Gender M F
Name Relationship Marital Yes No Gender M F
Name Relationship Marital Yes No Gender M F
Name Relationship Marital Yes No Gender M F
Name Relationship Marital Yes No Gender M F
Building Preference
(Please rank your preference of building- If you will not accept any property, please choose a "n/a" next to that building)
Montefiore 1 1st 2nd 3rd N/A Apartment Size Preference  
Montefiore 2 1st 2nd 3rd N/A 1st Choice: Studio One Bed Two Bed
Riverdale 1st 2nd 3rd N/A 2nd Choice: Studio One Bed Two Bed N/A
Remarks
Please enter any additional information that may help us process your application. While we will consider any additional information here, please note that assignments are based on eligibility and availability.