U.s. Residency Verification Form

U.S. Residency Verification Form

Arizona state law requires that a person who is not a citizen or legal resident of the United States or who is without lawful

immigration status is not entitled to classification as an in-state student pursuant to A.R.S. Section 15- 1 802 or entitled to classifi-

cation as a county resident pursuant to A.R.S. Section 15- 1 802.01. Failure to provide the information requested below may result

in your being now classified as out-of-state for tuition and fee purposes. The responsibility of providing the proper residency

classification is placed upon the student. Any student who falsifies his/her residency may be subject to dismissal from the

college and/or criminal action.

To verify U.S. residency status, you must provide at least one (1) of the acceptable documents listed on the back of this form.

Æ

PLEASE PRINT

NPC Student ID Number: ___________________________________________

Legal Name: ____________________________________________________________________________________________________________

Last

First

Middle

Date of Birth: ______ /______ /____________

(mm/dd/yyyy)

q

United States Citizen

q

Legal Immigrant/Permanent Resident

Date of Issue: __________________________________________________________________________________________________ and

• Alien Registration Number: _____________________________________________________________________________________

q

Lawful Refugee or Asylee

Date of Issue: __________________________________________________________________________________________________ and

• Alien Registration Number: _____________________________________________________________________________________

q

Legal Non-Immigrant

• Specify Immigration Classification: __________________________________________________________________________ and

• Date of Expiration: ___________________________________________________________________________________________ and

• Alien Registration Number or I-94 Number: _____________________________________________________________________

q

Do Not Qualify for Any of the Above

q

Country of Citizenship: ___________________________________________________________________________________________

u I certify that the answers on this form are true, correct and complete. I have attached at least one of the acceptable documents

listed on the back of this form.

____________________________________________________________________

____________________________________

Signature of Student

Date

All of the information on this form is in compliance with the Family Education Rights and Privacy Act of 1974. The Act’s provisions are explained in the General Catalog.

t FOR INTERNAL USE ONLY t

Document Type: _________________________________________________ Document Number (if any): ______________________________________

Issuing Authority: ________________________________________________ Expiration Date (if any): __________________________________________

Data Entry/Date _________________________________________________ Semester/Year: ___________________________________________________

Public Notice of NoNdiscrimiNatioN: Northland Pioneer College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or

treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is

the Director of Human Resources, 2251 E. Navajo Blvd., Holbrook, Arizona 86025, (800) 266-7845. The Section 504 Compliance Officer is the Coordinator of Disability Resource and Access, 1001 W. Deuce of Clubs, Show

Low, Arizona 85901, (800) 266-7845. The lack of English language skills will not be a barrier to admission and participation in vocational education programs. Revised 2-12

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