1a. IntroSUS 2003 - University of Maryland University College

Application for Admission Page 4Name _______________________________________________________ Social Security number _________ - _________ - ________The student applicant is responsible for completing #26–35.26. Are you residing in Maryland primarily to attend an educational institution? ■ Yes ■ No27. Permanent address ______________________________________________________________________ Apt. no. __________City ___________________ County ________________ State _______ Zip+4/Postal code ___________Country_____________How long have you lived at this address? Yrs _______ Mos _______If you have lived less than one year at this address, please provide the following information.Previous address ____________________________________________________________________ ____ Apt. no. ___________City ___________________ County ________________ State _______ Zip+4/Postal code ___________Country_____________How long did you live at this address? Yrs _______ Mos _______28. Are all, or substantially all, of your possessions in Maryland? ■ Yes ■ No29. Do you have a valid driver’s license? ■ Yes ■ Noa. If yes, provide the initial date of issue. From which state was the license issued?b. Were you previously licensed to drive in another state? ■ Yes ■ No30. Do you own a motor vehicle? ■ Yes ■ Noa. If yes, provide the initial registration date. In which state?b. Was your motor vehicle previously registered in another state? ■ Yes ■ No31. Are you registered to vote? ■ Yes ■ NoIf yes, in which state?Were you previously registered to vote in another state? ■ Yes ■ No32. Have you filed a Maryland income tax return for the most recent year? ■ Yes ■ Noa. List the year(s) in which you filed a Maryland income tax return within the past three years.b. If you did not file a tax return in Maryland within the past 12 months, state the reason(s).Provide the original voter registration date (Mo/Yr).33. Are you currently paying Maryland income tax, either through payroll deduction or quarterly estimated payments? ■ Yes ■ NoIf no, why not?34. Do you receive public assistance from a state or local agency other than one in Maryland? ■ Yes ■ NoIf yes, please explain.35. I hereby certify that I have completed all questions and that the information given above is complete and accurate, and I understand thatsummary dismissal is the penalty for falsification of that information. • Provision of my Social Security number is voluntary; if I so desire,may request that another number be assigned to me for purposes of identification. • I understand and agree that, if I enroll in classesoffered at military sites, my name, student identification number, and other personal information may be released for security purposes.• In addition, I authorize the release of my e-mail address to participants in online classes for which I register. • UMUC distributes anannual information report, including campus security information, which is available to prospective students. If I so desire, I may contactthe vice provost for Student Affairs for additional information. • By signing below, I agree that the information in this application andall my records from any institution in the USM may be released (at the discretion of the releasing institution) to any other institutionin the System, in accordance with the System-wide policy on academic integrity. • In making this application, I accept and agree to abideby UMUC’s policies and regulations concerning drug and alcohol abuse and understand that the unlawful use of alcohol or drugs willsubject me to the penalties contained in those policies and regulations. If my circumstances change, affecting my residency status, I agreeto notify UMUC in writing within 15 days.Signature of applicant: ____________________________________________ Date of application (Mo/Day/Yr): ___________________A $30 nonrefundable fee must accompany this application (unless you have attended UMUC before). If you pay by check or money order,please write your Social Security number on the check. If you wish to pay by credit card, please fill out the information below.■ MasterCard ■ VISA Customer acct. no.: ___________________________________ Exp. date (Mo/Yr): ________________