Last Name: First Name:

UW Student W Number:

UW Apartment Street Address:

Apartment Number:

Contact Phone:

E-Mail Address (name@uwyo.edu):

Today's Date:

Vacating Date:

Rent Rate:

Forwarding Address & Phone Number:

Reason for Vacating:

BY SUBMITTING THIS FORM, YOU AGREE TO CHECK OUT OF YOUR APARTMENT ON THE “VACATING DATE” YOU HAVE LISTED.