Request For Residency Points - City Of Bridgeport, Ct Page 2
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1
2If renting property, please provide the following:
_________________________________
_______________________
NAME OF LANDLORD
PHONE NUMBER
2.
___
I do not own property outside the City of Bridgeport, CT.
___
I own property outside the City of Bridgeport, CT.
Where? Explain ______________________________________________
3.
___
My driver’s license indicates a Bridgeport, CT. address
____________________________
________________________
License Number
Expiration Date
___
My driver’s license indicates an address outside Bridgeport, CT.
4.
___
I own a motor vehicle registered in the City of Bridgeport, CT.
___
I own a motor Vehicle registered in a place other than Bridgeport, CT.
____________________
______________________
___________________
License Plate #
Make & Model of Vehicle
City or Town where vehicle is
registered
_________________________
___________________________
________________________
License Plate #
Make & Model of Vehicle
City or Town where vehicle is
registered
5.
___
I am a registered voter in the City of Bridgeport, CT.
___
I am a registered voter in another City/Town other than Bridgeport, CT.
___
I am not a registered voter
6.
___
I have a child/children who attend school in the City of Bridgeport, CT.
___
I have a child/children who attend school outside the City of Bridgeport, CT
___
I do not have a child or children
___
I have a child or children who are either too young or too old to attend school
________________________________________
___________________
Signature of Applicant requesting Residency Points
Date
STATE OF CONNECTICUT
AFFIDAVIT
County of _______________________________
On this _________________________Day of ___________________200___________, before me personally appeared
_______________________________________________________________to me known to be the person described in
and who executed this request for Resident Preference Form, who having been duly sworn before me, stated that all
statements contained therein, both in writing and in print, are true.
Note: If any material change or correction is made in this (Signature Officer)____________________________
application, such change or correction must be under oath.
(Official Title) ____________________________
Notary, Justice of Peace
(NOTE: DO NOT USE SEAL)
Revised 12/12/05
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