Office of Enrollment Services, 4000 Lancaster Drive NE, Building 2, Room 200,Salem, OR
Mailing Address: PO Box 14007, Salem, OR 97309-7070
Phone: 503.399.5001 Email: registrar@chemeketa.edu
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To request this publication in an
alter
native format, please call 503.399.5192.
8/5/2019 s:\registrar\forms\application to change residency.docx chemeketa.edu
Application to Change Residency
Residency for tuition purposes is determined at the time of admission to Chemeketa based on the information that the
applicant provides. Please refer to Chemeketa's official Residency Policy and Procedure 5120
(go.chemeketa.edu/policies) for more information.
Changes to residency status will be applied to the current or future terms only.
1. Compl
ete this form and submit it along with the required documentation to Enrollment Services, Salem
campus, Bldg 2, Room 200
2. In order to be considered for a change, Chemeketa requires proof of residency. A permanent residence
shall be verified by specific documentation. Please provide at least one document that includes a date
to show your physical presence and intent to reside in Oregon, your name, and your physical address
in Oregon. Such documentation may include, but is not limited to:
• Oregon Driver License or ID Card
• Bank account statements
• Selective Service registration
• Oregon State Income Tax form
• Recent Veteran: LES, DD214
• Current W-2
Active Duty military ID, copy of orders in
• Oregon Voter registration card
• Utility bills (gas, water, power, telephone)
• Immigration documents (Visa, change of
status application verification)
• Documentation of entry into a legal
agreement in Oregon (marriage, divorce,
• Documentation of ownership of residential
property or of continuous occupancy of
rented or leased property in Oregon
• Documentation of public assistance,
rehabilitation, unemployment or other
Student ID (
K#): Date: - -
Name:
__________________________________________________________________________________
Last, First, Middle
Addres
s: ________________________________________________________________________________
Street, City, State Zip
Cell Phone
(with Area Code): ______________ Email Address: ____________________________________
Note: Official communication from Chemeketa will only be sent to your student email
Whe
n did your current stay in Oregon begin? ________/________/__________
mm/dd/yyyy
Student
Signature____________________________________________________________________
Documentation provided:_________________________ Documentation Dated:_________________ Term Of Change:___________________
Change Approved: Yes No Processed By Initials:_______________________ Date Processed:___________________________
