Application For Admission Form (Page 2 of 2) in pdf

Learning for a Lifetime

Application for Admission

Section III

Florida Residency is a requirement of the Learning for a Lifetime program. This section must be completed in full by the person claiming

Florida Residency. Documents supporting the establishment of legal residence must be dated, issued or filed 12 months before the first day

of classes for the term for which a Florida resident classification is sought. All documentation is subject to verification.

Additional documentation other than what is required above may be requested in some cases.

Select one of the statements below. While more than one statement may be applicable, only one is required.

I am an independent person and have maintained legal residence in Florida for at least 12 months.

I am married to a person who has maintained legal residence in Florida for at least 12 months. I have now established legal

residence and intend to make Florida my permanent home (Required: Copy of marriage certificate, proof of residency status).

According to the United States Immigration and Naturalization Service, I am a permanent resident alien or other legal alien

granted indefinite stay and have maintained a domicile in Florida for at least months (Required: INS documentation, proof of

residency status).

I am a full-time instructional or administrative employee employed by a Florida public school, community college, or institution

of higher education, or I am the employee’s spouse or dependent child (Required: Copy of employment verification).

1. Name of student: ________________________________________

2. Social Security Number: _________-_________-_________

3. Name of person claiming Florida Residency: _______________________________________

4. Claimant’s relationship to student: _____________________________________

5. Claimant’s permanent legal address: __________________________________________________________________________________

6. Claimant’s telephone number: _(______)______________________________

7. Date Claimant began establishing legal Florida Residency (mm/dd/yyyy):_________/_________/________________

Information for at least two of the items listed in numbers 8-10 (below) is required to prove Florida Residency:

8. Claimant’s Florida voters registration number: ________________________________

Issue Date: _____________________

9. Claimant’s Florida drivers license number: ____________________________________

Issue Date: _____________________

10. Claimant’s Florida vehicle registration: FL License Plate# ________________________

Issue Date: _____________________

11. Non U.S. citizens only. Photocopies of both sides of your resident ID card must accompany this form.

Resident Alien Number: ______________________________________________

Issue Date: ______________________

Please provide a brief explanation of your activities for the last two years, including the city, state and dates. Please Print.

Activity

City, State

Dates (From—To)

I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification

as a Florida resident for tuition purposes. I understand that a false statement in this affidavit will subject me to penalties for making a false

statement pursuant to 837.06, Florida Statutes, and to BOG Rule 6C-6.001(6), F.A.C.

_________________________________________________________

_________________________________________________

Signature of Claimant (as listed in #3 above)

Date

Submit this completed form to One Stop Student Services by fax: 904-620-2414 or drop off: building 53 suite 1700 or mail to:

One Stop Student Services, University of North Florida, 1 UNF Drive, Jacksonville, Florida, 32224.

Received by: ________

Processed by: _________

Date:______________

Updated 1/20/2012

Date: _______________

Application For Admission Form Page 2

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