Name
LAST FIRST M
Address
NUMBER/STREET CITY STATE ZIP
Phone
High School
Email
Social Security Number
Date of Birth
A
re you a U.S. Citizen? Yes
No — If not, please complete the following:
Are you a Permanent Resident? Yes. Alien registration number No
If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status:
PLEASE CHECK THE IN-STATE OR REDUCED TUITION ELIGIBILITY CATEGORY THAT APPLIES TO YOU:
Are you under 18 years old?
Yes. Please provide parent/guardian residency documentation. No
I have been a Massachusetts resident for six (6) continuous months and intend to remain here. As proof of my intent to remain in Massachusetts,
I POSSESS AT LEAST 2 OF THE FOLLOWING DOCUMENTS, which I shall present to the institution upon request. These documents* are dated
within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution
reserves the right to make any additional inquiries regarding the applicant’s status and to require submission of any additional documentation it deems
necessary. Please check-off those documents you possess as proof of your intent to remain in Massachusetts.
Valid driver’s license
Utility bills*
Employment pay stub*
Valid car registration
Voter registration*
State/federal tax returns*
MA high school diploma
Signed lease or rent receipt*
Military home of record*
Record of parents’ residency for
un-emancipated person*
Other
I am an eligible (ME/NH/VT/RI/CT) participant in the New England Board of Higher Education’s Regional Student Program.
I am a permanent legal resident of the state of New York.
I am a member of the armed forces (or spouse or un-emancipated child) on active duty in Massachusetts.
CERTIFICATION OF INFORMATION
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for
disciplinary action up to dismissal, with no right of appeal or to a tuition refund.
Student Signature Date
Parent/Guardian Signature Date
(REQUIRED IF APPLICANT IS UNDER 18 YEARS OLD.)
FOR OFFICIAL USE ONLY — DO NOT WRITE BELOW THIS LINE
I have reviewed the above information in order to determine this individual’s eligibility to receive the in-state tuition rate. Based on my review I have
determined that this individual:
IS eligible for the in-state tuition rate.
IS NOT eligible for the in-state tuition rate.
I am unable to make a determination at this time. The following additional information has been requested from the applicant:
Authorized Signature
Date
Berkshire Community College is an afrmative action/equal opportunity institution and does not discriminate on basis of race, creed, religion, color, gender, gender identity, sexual orientation, age, disability, genetic information,
maternity leave, military service, and national origin in its education programs or employment, pursuant to Massachusetts General Laws: Chapter 151B and 151C; Title VI, Civil Rights Act of 1964; Title IX; Education Amendments
of 1972; Section 504; Rehabilitation Act of 1973; Americans with Disabilities Act; and regulations promulgated thereunder, 34 C.F.R. Part 100 (Title VI), Part 106 (Title IX) and Part 104 (Section 504). All inquiries concerning ap-
plication of the above should be directed to Melissa Loiodice, Director of Human Resources and Afrmative Action Ofcer; and Coordinator of Title IX and Section 504, at 413-236-1022,SBA Annex, Room A-20.
MONTH/DAY/YEAR
Massachusetts Community Colleges
In-State Tuition Eligibility Form
(Please type or print)
