TR 4/1/19
Admissions & Records Office
Building 700, First Floor
25555 Hesperian Blvd.
Hayward, CA 94545
Admissions & Records Office
Building 1600, Second Floor
3000 Campus Hill Drive
Livermore, CA 94551
AB 2364 HIGH SCHOOL NON-RESIDENT EXEMPTION REQUEST
This form is to be used in the event that you have applied to Las Positas or Chabot College for the purpose of enrolling
under the Concurrent Enrollment program and were coded as a non-resident of California.
To be eligible for this exemption, you must meet all of the following:
Completed all steps and documentation as required under the respective college’s Concurrent Enrollment program
Approved/admitted under the respective college’s Concurrent Enrollment program
You are a U.S. citizen, permanent resident, DACA grantee, or alien without lawful immigration status
(undocumented)
INSTRUCTIONS
: To qualify for this exemption, fill out the required fields below and bring this form to the Admissions &
Records Office of the college that you most recently applied to and/or is currently indicated as your Home Campus.
STUDENT INFORMATION
W
Last Name, First Name, Middle Initial
Student ID #
EXEMPTION REQUEST
I am requesting an exemption of non-resident status at the following institution (PICK ONE):
Las Positas College
Chabot College
Check one box only that applies to you:
U.S. Citizen (Eligible for exemption)
Permanent Resident (green card holder) (Eligible for exemption)
(DACA) Deferred Action for Childhood Arrival grantee (Eligible for exemption)
Alien without lawful immigration status (undocumented) (Eligible for exemption)
Nonimmigrant alien as defined by federal law (nonimmigrant aliens have been admitted to the United States
temporarily and include, but are not limited to, foreign students holding F visas and exchange visitors holding J
visas) (
Not
eligible for exemption)
STUDENT AGREEMENT
By signing below, I certify that the information provided on this form is truthful and accurate and that I meet all
requirements listed on this form.
Student Signature
Date
IMPORTANT NOTICE
AB 2364
allows community colleges to exempt special part-time students, other than nonimmigrant aliens, as defined,
from paying all or parts of the non-resident tuition fee if that student is admitted under the Concurrent Enrollment
program.
ADMISSIONS & RECORDS OFFICE USE ONLY
HSNR
Student attributed
Student notified
Done by: ______________
Date: _________________
Date
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