Minnesota - Wisconsin Application Form For Reciprocity Benefits Page 3
ADVERTISEMENT
1
2
3
4State of Wisconsin
Application for Reciprocity Benefits
State of Minnesota
WI Higher Educational Aids Board
Minnesota-Wisconsin Reciprocity Program
MN Office of Higher Education
Reciprocity Program
2015-2016 Academic Year
Reciprocity Program
PO Box 7885
(Fall Term 2015-Summer Term 2016)
1450 Energy Park Drive, Suite 350
Madison, WI 53707-7885
St. Paul, MN 55108-5227
MN or WI residents enrolling into colleges are
(608) 267-2209
(651) 642-0567 or 1-800-657-3866
no longer required to submit a paper
application if they apply online
(WI resident apply online)
(MN resident apply online)
Send Completed Application to Appropriate Agency
◄ Read instructions before completing application.
1. Name (last, first, middle initial):
2. Social Security Number
FOR OFFICE USE ONLY
County
2a. Gender
3. Birth date (mm/dd/yy):
4. County of Residence:
( ) Male ( ) Female
Origin
5. Home Address (street address, city, state, zip code
)
Major
Class
5a. I (student) have resided at this address since _______/_______/_______ (month/date/year).
Terms
5b. If you have lived at this address for less than one year, list addresses and dates of prior places of
residence for the previous five years in the space provided on the back of this application.
School
5c. If you have not resided in the state where you are claiming residency during the past twelve
months, explain any circumstances that may entitle you to reciprocity benefits (use the back of
Received __________________
this form or a separate piece of paper).
5d. Address while attending school during the 2015-2016 academic year, if known (street, address, city, state & zipcode):
6. Name of High School Attended: (including home school)
City:
State:
Year Graduated:
6a. Year and State in which you earned GED (If applicable)
7. Parent’s or Guardian’s Name:
Telephone No.
Parents Resided Here Since:
(
) _________-_____________
________/________/________
Street Address:
City, State & Zip code:
8. Are you currently in the Military?
NO ( )
YES ( ) -- If YES, stationed at (Base, City, State): ______________________________
___________________________________
If yes, attach documentation showing home of record.
9. Are you a U.S. Citizen?
YES ( )
NO ( )
If NO, enclose a photocopy of your visa/green card or I-94 visa.
10. (WI residents only) Have you registered for Selective Service? NO (
)
YES (
) If yes, please provide “Registration Number”
______________________ If you are male and 18 years or older, WI State statute 39.28(6) requires you to provide your Selective Service
registration number for WI state aid. This requirement does not apply to males born prior to 1960. (Find your individual selective service
number at Click on "Verify a Registration".)
11
Name and location of college/university that you plan to attend for the 2015-2016 academic year and for which you are seeking tuition
.
reciprocity benefits:
See attachment for who is eligible.
12. Class level – For 2015-2016
Graduate ( )
Undergraduate: Fresh. ( ) Soph. (
)
Jr. ( )
Sr. ( )
Other ( )
13a. Course of Study/Major:
13. Terms of Enrollment: FALL 2015 ( ) Winter Interim 2015 ( ) SPRING 2016 ( )
SUMMER 2016 ( )
14. List colleges that you previously attended, are currently attending, dates of enrollment (from MM/DD/YY to MM/DD/YY), and
enrollment level (less than half-time or half-time or more) at each institution in the space provided on the back of this application form.
Complete page 2 of the application form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application Form For Certificate Of Attestation Of Exemption From New York State Workers' Compensation And/or Disability Benefits Insurance Coverage - New York State Workers' Compensation Board
Legal
Application Form For The Renewal Of Trinidad And Tobago Machine Readable Passport (applicants 16 Years And Over)
Life
Related Categories
Parent category: Business