Application For Reciprocity Benefits (Page 3 of 4) in pdf

Application for Reciprocity Benefits

Minnesota-North Dakota Reciprocity Program

2014-2015

Academic Year

Fall 2014 – Summer 2015

MINNESOTA

NORTH DAKOTA

MINNESOTA OFFICE of HIGHER

NORTH DAKOTA UNIVERSITY SYSTEM

EDUCATION (OHE)

Reciprocity Program

1815 Schafer St, Suite 202

1450 Energy Park Dr, Ste 350

Bismarck ND 58505-1217

St Paul MN 55108-5227

(701) 224-2541

(651) 642-0567 or 1-800-657-3866

reciprocity-programs/

MN residents are no longer required to submit a

ND residents may apply online at the NDUS Web site.

paper application if they apply online on the OHE

Web site.

Complete application form and mail to appropriate agency as indicated above

1. Name (last, first, middle initial):

FOR OFFICE USE ONLY

County

3. Birthdate (mm/dd/yy):

2. Social Security Number:

4. County of Residence:

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 2014-2015 academic year, if known (street, address, city, state & zip code):

6. Name of High School Attended: (including home school)

City:

State:

Year Graduated:

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. Name and location of college/university that you plan to attend for the 2014-2015 academic year and for which you are seeking tuition

reciprocity:

Professional: Dentistry ( )

11. Career & Technical Ed: Class Level 1

Year ( ) 2

Year ( )

Higher Ed

Veterinary Medicine ( )

Graduate ( )

Higher Ed: Fresh. ( )

Soph. ( )

Jr. ( )

Sr. ( )

Other ( )

12. Terms of Enrollment:

FALL 2014 ( )

SPRING 2015 ( )

SUMMER 2015 ( )

check all that apply

13. Course of Study/Major:

Complete page 2 of the application form

Application For Reciprocity Benefits Page 3

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