North Carolina Residence & Tuition Status Application Form (Page 2 of 2) in pdf

North Carolina Residence & Tuition Status Application Form Page 2

6. If any of the documents identified above were issued before the date you provided in response to Question # 4,

please identify which ones and provide their date(s) of issue:

REQUIRED DOCUMENTATION

A. Please provide a copy of every document identified in Question # 5, above, if permitted by law. If not permitted,

be prepared to provide us with each applicable document for inspection upon request.

B. Please provide a copy of any documentation that you believe may be relevant.

SIGNATURE AND CERTIFICATION

I certify that all information I have provided is true and accurate to the best of my knowledge. I understand that

intentionally providing false or misleading information may result in revocation of my admission and/or a violation under

the institution’s code of conduct.

I also understand that I must advise the University of any changes in facts or circumstances that may affect my state

resident status. If, at any time, it is discovered that my visa or immigration status was obtained fraudulently, the

University shall have the right to seek and collect payment of full, out-of-state tuition, along with any fees and costs

associated with such collection. My eligibility may be reviewed by the University at any time.

I understand and agree that the University of North Carolina at Pembroke (UNCP) may verify information with regard to

this application. I understand that UNCP may divulge the contents of this application only as permitted under state laws

and/or under the Family Educational Rights and Privacy Act of 1974, if I am, or have been, in attendance at this

institution.

Signature of Applicant: ____________________________________________

Date: ________________________

Signature of parent or guardian: _____________________________________

Date: ________________________

(if applicant is under 18 years of age)

This publication is available in alternative formats upon request. Call Disability Support Services, D. F. Lowry Bdg. , 910-521-6695.

North Carolina Residence & Tuition Status Application Form Page 2