A one-year residency requirement is enforced in order for a student to be classied as an in-state student for tuion purposes.
The responsibility of registraon under the proper residence classicaon is placed upon the student. Any student who is found to be classied
improperly shall be required to pay full tuion, or be subject to dismissal from the college. In doubul cases a cered statement of the facts or
documentaon of the facts may be required. (See Arizona Revised Statutes §15-1802)
(Please print or type)
_______________________________________________________________________________________________ 2. Student ID Number _________________
Last First Middle
3. Phone Number (with Area Code) _______________________________________ 4. Email __________________________________________________
5. Legal Address: _________________________________________________________ 6. Mailing Address (if different): ______________________________________
7. When did your current residency in Arizona begin? 8. What are your present sources of income?
__________/__________/__________ Self-Supporting (Self/Spouse) q Parent or legal guardian q
mm dd yyyy If parent/ legal guardian, their address(Legal guardianships ends at age of 18.
Court documentation required):
9. If you have been attending another college or university, please list the institution and the dates of attendance.
Institution: ____________________________________________________________ ________/ ________/ ________ t o ________/ ________/ ________
mm dd yyyy mm dd yyyy
At the above institution, did you pay “resident” q or “non-resident” q tuition?
Mark one (1) of items 10 through 18, and provide the requested addional documentaon with this Domicile Adavit.
10. q I am registered to vote in Arizona? (Aach Copy of Voter Registraon) County _______________________ Date Registered__________
11. q I have been employed in Arizona during the past two years: (Aach Notarized Leer(s) from Employer(s) with Date of First Hire)
Employer___________________________________________________________ Employer ________________________________________________________
Place of employment _______________________________________________ Place of employment _____________________________________________
Date of employment ______/_______/_______ to _______/_______/_______ Date of employment _____/_______/_______ to _______/_______/_______
mm dd yyyy mm dd yyyy mm dd yyyy mm dd yyyy
12. q An employer required that you, your spouse or parent be transferred to Arizona? (Aach Notarized Leer from Employer)
If yes, provide name of employer __________________________________________________________________________________________________________
13. q I led an Arizona State Income Tax Return for past two years: (Aach Copy of First & Last Page of AZ Tax Returns)
Tax year ___________________ Tax year _________________________
14. q I have a current Arizona driver’s license (Aach Copy of Driver’s License issued at least 1 year ago): License Number __________________
Date issued __________________ Renewal: No q Yes q Original date issued ___________________________________________________
15. q My Motor Vehicle is registered in Arizona. (Aach Copy of Previous Year’s Vehicle Registraon): License Number _________________________
Date issued __________________ Renewal: No q Yes q Vehicle owned by you? No q Yes q
16. q I am currently in the military or a military dependent. If active duty, where are you stationed?______________________________________
Aach a Copy of Request & Authorizaon for Permanent Change of Military Staon (AF Form 899 and/or DD214)
If you are a military dependent, where is parent/guardian/spouse stationed? _________________________________________________________________
17. q I am a resident member of an Indian tribe whose reservation land lies in this state and extends into another state.
If yes, which reservation _____________________________________________________ (Aach Chapter House Statement/NN Voter Registraon)
18. q I recently married and my spouse previously established one-year residency in Arizona.
If yes, attach a Copy of Marriage Cercate AND a Copy of the First & Last Page of Spouse’s Previous Year’s AZ Tax Return.
My residency status: U.S. Resident q Non-USA Permanent Resident q Refugee or Asylee q Non-USA q Non-Immigrant q
Attach a Copy of your Visa Visa Type _________ Date Issued _______
By submitting this form, I certify that the information I provided is accurate. I have not given false or misleading information, I understand that if it is
found to be otherwise, it is sufﬁcient cause for rejection or dismissal.
__________________________________________________________________________________ Date ___________________________________
Revised 03/15/19 • MPR•ECR • Marketing/Forms/R&R/DomicileAfdavit
APPROVED_____ DENIED _____ DATE __________
NPC Rep Signature_____________________________
PUBLIC NOTICE OF NONDISCRIMINATION: Northland Pioneer College does not discriminate on the basis of race, color, national
origin, veteran status, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational
programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Afrmative
Action Compliance Ofcer is the Director of Human Resources, 2251 E. Navajo Blvd., Holbrook, Arizona 86025, (800) 266-7845. The Section 504
Compliance Ofcer is the Coordinator of Disability Resource and Access, 1001 W. Deuce of Clubs, Show Low, Arizona 85901, (800) 266-7845. The
lack of English language skills will not be a barrier to admission and participation in vocational education programs. Revised 9-12-14
click to sign
click to edit
click to sign
click to edit