Form Cr-602 - Michigan Indian Tuition Waiver Application printable pdf download

MICHIGAN INDIAN TUITION WAIVER APPLICATION

MICHIGAN DEPARTMENT OF CIVIL RIGHTS

110 W. Michigan Ave., Suite 800, Lansing, MI 48933

517/241-7748

TO BE COMPLETED BY STUDENT – Please print clearly in ink or type

DEMOGRAPHIC INFORMATION:

NAME:

Last

First

Middle

Maiden

________________________________________________________________________________________________

MAILING ADDRESS: Street

City

State

Zip

________________________________________________________________________________________________

CONTACT INFO: Phone #

Cell phone #

Email address:

_______________________________________________________________________________________________

BIRTHDATE:

SOCIAL SECURITY #

MI DRIVERS LICENSE/STATE ID #

__ __/__ __/__ __

XXX-XX-__ __ __ __

_________________________

Are you a Michigan resident? Y

If yes, have you resided in Michigan for the last 12 consecutive months? Y

Have you been accepted at your enrolling institution? Y N

If yes, please list your student ID # if available: _________________

Transfer/Dual Enrollment Request (check one)

_____ I want to transfer my MITW from ______________________________ to _________________________________________.

_____ I will be dual enrolled at (schools) ___________________________________ and ___________________________________.

SCHOOL INFORMATION:

Name of institution: ________________________________________________________________________

Address of institution: _______________________________________________________________________

Expected degree: ___ Certificate ___ Associates ___ Bachelors

___ Masters

___ Doctorate

___ Medical

___ Law

Enrollment Information: Semester/Term: ________ Year: ________

full-time _____

part-time _____

TRIBAL INFORMATION:

Please provide the name and address of the US Federally Recognized Tribe of which you are a member.

Tribe: _____________________________________________________________________________________________

Address: ___________________________________________________________________________________________

Please provide your Tribal Enrollment (ID) #:_______________

1. I declare that the information which I have provided on this form is true, correct and complete to the best of my knowledge.

2. I agree that this information may be shared with my enrolling institution, my Tribe and may be used for statistical purposes by the

MITW program.

3. I declare that by signing this form I have lived in Michigan for twelve (12) consecutive months prior to the date on this application

and that I am currently a Michigan resident.

Applicant’s signature: ___________________________________________

Date: ____________________

TO BE COMPLETED BY TRIBE – Please print clearly in ink or type

I hereby certify that the above named applicant is ¼ (one quarter) or more degree of Indian blood quantum according to the available

Tribal and/or Federal records.

AND

I hereby certify that the above named applicant is an enrolled member of this Tribe, which is US Federally Recognized.

Certifying Signature: ____________________________ Certifying Official’s Name (print): ________________________

Title: _________________________________________________ Date: __________________________________

Name of Tribal Nation: ____________________________________

Phone: _________________________________

Address: _________________________________________________ City/State/Zip: ___________________________

CR-602

Revised 6/23/11

Form Cr-602 - Michigan Indian Tuition Waiver Application

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