Residence Information Affidavit - University Of Oregon
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Status:
DEP
INDEP Date:
Effective Term:
Resident
Non-Resident
Residence Classification Officer:
Notes:
Residence Information Affidavit
(Please print or type)
Section 1: Applicant Background
Name (print)
Phone (
)
Last
First
Middle
Present Mailing Address
Number & Street
City
State
Zip
Email ______________________________________________________ Student ID Number
Permanent Mailing Address
Number & Street
City
State
Zip
Age
Date of Birth
Place of Birth
1
For what term are you seeking residence classification?
Fall
Winter
Spring
Summer
Year
Have you previously applied at this institution for a change in residence status?
Yes
No
2
If “yes,” indicate term ____________________ and year ________________
Where and when did you graduate from high school? City/State
Grad Date
3
4
When did your most recent continuous stay in Oregon begin?
Month
Day
Year
5
Since your most recent continuous stay in Oregon began, have you attended a private or public college, university or community college?
Yes
No
Name of Institution
Term
Year
Hours
6
If you answered “yes” to question 5, please indicate the
institution(s), term, year and hours of enrollment in the table
provided.
(Attach additional pages if necessary)
7
Have you ever paid in-state tuition at a public college or university
(including community college)?
Yes
No
8
If “yes” to question 7, please indicate where and dates of attendance.
From _______ to__________ Name of institution _______________________________ Location __________________________________
From _______ to__________ Name of institution _______________________________ Location __________________________________
Have you attended an Oregon higher education institution as a National Exchange, WICHE/WUE, or Reciprocity student?
9
Yes
No
If “yes,” give program and dates
10
Are you a citizen of the USA?
Yes
No If “no,” you must attach a copy of both sides of Resident Alien Card, Form I-94, or
other documentation reflecting your visa type or current status.
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