EVERGREEN VALLEY COLLEGE
3095 Yerba Buena Rd.
San Jose, California 95135
Name:
Address:
What is your Country of Citizenship?:
Date your CURRENT stay in California began: /
Day Year
*Proof Required
US Citizen - Met the physical and Intent Requirements (proof attached)
Alien#_______________________ Date applied _________________ Prior Immigration Status ___________
Are you applying for a change of status that allows you to establish California Residency? _________________
**If yes, what is the Status? _________________ Date applied ___________________ Date granted _________
Refugee/Asylee Alien# ______________________________ Date applied _______________________
Prior Immigration Status ____________________________
Date:
FOR OFFICE USE ONLY
SPRO/ASPR Date chg'd to ___________________for_________________Term Re-billed on__________
Date chg'd to ___________________for_________________Term Re-billed on__________
FINF Updated
STRK Has original application been verified? _________________________
Approved By A&R Staff
Date:
Rev.4/2020
*Examples of Proof: Ownership, leased or rented property, Voter registration and proof you have voted, Valid CA driver's License or ID
dated over one (1) year ago, Federal and State income tax forms, Resident Alien Card and/or Visa documentation.
US Citizen - and I qualify for AB540 (The law that provides for an exemption from non-resident tuition for certain non-resident
students. Affidavit must be submitted .)
Other - Undocumented and I qualify for AB540 (The law that provides for an exemption from non-resident tuition for certain non-
resident students. Affidavit must be submitted .)
**If you have applied for a change of status from a Visa that cannot establish residency to a Visa that can establish residency, you may not be
classified as a resident until the Visa has been granted (proof is required.)
I declare under penalty of perjury that the information submitted is true and correct.
Student's Signature (required):
Received By:
Date:
Student I.D. or SS#:
Date of Birth:
TO BE COMPLETED BY ALL STUDENTS
Month
Do you intend California to be your permanent residence?
Please check one and attach any and all documentation/proof of State and US Residency
Note: Documentation is required in order to process any changes in residency.
Semester:
click to sign
signature
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signature
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