I/we certify that all of the information provided on this application is true and accurate. I/we understand that this form is a legally binding document and that if I/
we provide fraudulent information, the student may be subject to repayment of tuition and dismissal. I/we agree to furnish the college with supporting docu-
mentation related to my application, if requested to do so. The student understands and agrees to comply with the academic and student conduct policies of
the college.
4. Present County or City of Residence 5. How long have you lived in Virginia?
11. Do you hold a valid driver’s license? YES NO
If YES, in which state? Date obtained:
JSR ID: High School Name:
Do your parent(s)/legal guardian(s) provide 50% or more of your financial support or claim you as a tax dependent? YES NO
If YES, your PARENT(S)/LEGAL GUARDIAN(S) must complete Part B.
If NO, do any of these apply to you? (Please check all that apply)
Married
Ward of the court or was a ward of the court until age 18
If both parents are deceased, no adoptive or legal guardian
You have legal dependents other than your spouse
If you checked any of these, YOU MUST complete Part B.
If you checked none of these, YOUR PARENT(S)/LEGAL GUARDIAN(S) MUST complete Part B.
9. Are you a registered voter? YES NO If YES in which state? Registration Date:
Please complete Parts A and B, sign at the bottom to be considered for in-state student status under Section 23-7.4 of the Code of Virginia.
PART B: TO BE COMPLETED BY PARENT(S) OR LEGAL GUARDIAN(S). (PLEASE PRINT)
10. Did you own or operate a motor vehicle during the past year? YES NO
If YES, in which state was it registered during the past year?
Date registered: In whose name was it registered?
Social Security Number Last Name First Name Full Middle Jr.,3rd
PART A: TO BE COMPLETED BY STUDENT (PLEASE PRINT)
X Applicant (Student): DATE:
X Parent/Legal Guardian: DATE:
13. Is the applicant or any member of the applicant’s immediate family an active duty member of the US Armed Forces? YES NO
If YES, relationship to student:
12. If you were employed in Virginia, but lived outside of the state of Virginia, did you earn at least $14,500? YES NO
6. Where have you lived for the past two years, listing the most current address first:
FROM (mm/dd/yy) TO (mm/dd/yy) Street Address City State Zip
7. Have you been employed for the past year? YES NO
If YES, in which state?
3. Your citizenship status: U.S. NON-U.S If non-U.S., Visa Type:
2. Name of person completing Part B:
Do you as a PARENT/LEGAL GUARDIAN grant permission for your son/daughter to enroll in the college classes? Yes No
1. Who is completing Part B? PARENT LEGAL GUARDIAN (court appointed) Daytime Phone:
If Legal Guardian, please provide court documents.
8. Did you file a tax return or pay income taxes on all earned, taxable income to Virginia for the prior year? YES NO
If NO, to what state(s) did you file a return or pay income taxes?
Application for In-State Tuition
For Dual and Concurrent Enrollment Applicants
JSRCC Form No. 11-0024 Residency for Dual and Concurrent Enrollment Applicants form 10/2013
This institution promotes and maintains educational opportunities without regard to race, color, sex, ethnicity, religion, gender, age (except when age is a bona fide occupational
qualification) handicap, national origin or other non-merit factors. Employer, date of birth, social security, sex and race information are optional and used for research, reporting and
management of student records.
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