College Student Residency Application / Appeal Intake Form

Student Name

First Name

Last Name

Year in School

e.g. sophomore or professional school or PhD candidate

Home Address

Student's Phone

(###)

###

####

Student's Personal Email

Student's School/University Email

Parent Name

Complete if a parent is involved

First Name

Last Name

Parent's Phone

If parent is involved

(###)

###

####

Parent's Email

If parent is involved

Referral Source

Name of College / University Attending / Program

Have You Already Submitted an Application for In-State Residency?

Yes

Not Sure

Has Your In-State Residency Request Been Denied?

Yes

Not Sure

Not Applicable

Brief Description of Situation