hartnell college fall 2009

Residency CertificationPart I - All students must answer the following 12 questionsState laws regulate admission of students on the basis of legal residency. This statement is a certification necessary to administer the laws. If additional information is needed todetermine your residence status, you will be required to complete a supplemental residence questionnaire and/or to present evidence in accordance with Educational Code Sections68040 et seq. The burden of proof to clearly demonstrate both physical presence in California and intent to establish California residence lies with the student.Please PrintName:____________________________________________________________________________1. Place of birth: ________________________________ _________________________City/State(State or Country)2. Where have you resided the past 24 months?FromTo(City)(City)(City)3. Are you unmarried and under 19 years of age?4. Filed Personal state income tax to another state?5. Voted in another state?6. Attended an out-of-state education institution as a resident of that state?7. Declared residency in another state for income tax purposes?8. Petitioned for divorce in another state?9. Had a valid drivers license in another state?10. Register a vehicle in another state11. Are you a public school credentialed employee?12. Are you a seasonal agricultural employee or dependent?Yes Complete questions 4 - 10below about your parents.Will you be on active duty in the armed services stationed in California on the opening day of the semester in which you plan to enroll?Were you discharged from the Armed Forces within the last year?(State)(State)(State)NO456789101112Are you the dependent or spouse of a person on active duty in the armed services stationed in California on the opening day of the semester in which you plan to enroll?(If "YES") When did his/her current duty in California begin? ________________________________________________________ Submit reporting ordersFromFrom(Month/Day/Year)(Month/Day/Year)(Month/Day/Year)ToToYES(Month/Day/Year)(Month/Day/Year)(Month/Day/Year)No Complete questions 4 - 10about yourself.If yes, what year?Part II - To be completed by active military persons, veterans discharged within the last year, or dependents(If "YES") When did your current duty in California begin?Is California indicated on your last Leave and Earning statement? Yes Submit your last LES. NoYesNoYesYes_________________Date of discharge _______ Submit DD214. What State?. __________NoNoFor determination of California Residency, minors may need to include their Parents Residency InformationPart III - If you are under 19 years of age when classes begin-complete this boxGive names and permanent legal residence for the following persons. If deceased , enter word "deceased"SHOW ADDRESS TO COVER AT LEAST TWO YEARS (Legal/Permanent Address-Do not use P.O. Box Number.)FATHER'SNAME : _____________________________________________________________________ U.S. Citizen YesCURRENTADDRESS:______________________________________________________________________________________________________________Number Street City State Zip Since What DatePrevious Address: _________________________________________________________________________________________________________________MOTHER'SNAME : _____________________________________________________________________ U.S. CitizenCURRENTADDRESS:___________________________________________________________________________________________________________________Number Street City State Zip Since What DatePrevious Address: _________________________________________________________________________________________________________________YOUR ADDRESSCURRENT :Number Street City State Zip Since What DatePrevious Address: _________________________________________________________________________________________________________________YesNoNo