Fillable Form modified 3/27/2015: Graduate Reactivation (Old Dominion University)

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Form modified 3/27/2015: Graduate Reactivation (Old Dominion University)

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The Form modified 3/27/2015: Graduate Reactivation (Old Dominion University) form is 4 pages long and contains:

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  • 9 check-boxes
  • 157 other fields

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File type: PDF

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Graduate Reactivation
The purpose of this form is to reactivate a previous admission to Old Dominion University. Complete this
form and email to gradadmit@odu.edu.
1. LAST name 2. FIRST name 3. Initial 4. Previous name(s) or maiden name
M F
5. Student ID # 6. Date of birth (MM-DD-YYYY) 7. Gender 8. Email address
9. (Current) Address 10. Apt. 11. City 12. State/Province
13. Zip 14. Country 15. Home phone number 16. Alternate (work, cell) phone
17. Please indicate all institutions you have EVER attended
Institution & city, state Date(s) of attendance Institution & city, state Date(s) of attendance
18. Date of last enrollment at ODU (MM-DD-YYYY) 19. Indicate your previous program of study:
20. Desired term of readmission 21. If you plan on taking courses at a site OTHER THAN MAIN CAMPUS, please indicate
Fall
Spring 20
Summer
22. Have you ever been academically or non-academically dismissed from any institution (including ODU) for any reason? Yes No
23. [If applicable]Please provide name of institution and date of dismissal
24. Are you associated with the military? If no, continue to question 24. If yes, please indicate your affiliation (check all that apply):
Active Duty Retired Spouse Dependent
Reservist Veteran Honorably discharged
I understand that…
Yes N/A
25. It is my responsibility to notify my graduate program of my intentions.
26.
I must submit all official transcripts from institutions attended during my separation to the Office of Graduate Admissions.
27.
If my separation has been more than five years, I must reapply and submit ALL transcripts from all institutions I’ve EVER attended to
the Office of Graduate Admissions.
28. Returning students who have been separated from Old Dominion University for one calendar year or more must complete a new
Application for In-State Tuition (Domicile Form) and send it to the Office of the Registrar. Students in this category will be charged the
out-of-state tuition rate when returning until the new domicile status is determined.
Signature of applicant Print Date
Email upon completion to gradadmit@odu.edu
Form modified 3/27/2015
I understand that the information in the below section is required. I further understand that, should any of my
answers change after I have submitted my application, it is my responsibility to inform the Old Dominion University
Office of Admissions immediately. *
I also understand and agree that if I am offered admission to Old Dominion University and choose to enroll, I have
a continuing obligation to report to the Office of Student Conduct and Academic Integrity any convictions, other
than minor traffic violations, that occur
subsequent to signing this application. This obligation extends during any
periods of enrollment at the university. My failure to provide this information may subject me to disciplinary action
under the Code of Student Conduct. *
Have you ever been:
Removed, dismissed or expelled from any
school or academic program at the secondary or post-secondary level?*
Yes
No
Convicted of a violation of any local, state or federal law, other than a minor traffic violation? *
Convicted or received adjudication as a juvenile for a violation of any local, state, or federal law, other than a minor
traffic violation? *
Are you currently:
On court-ordered supervised or unsupervised probation or under the terms of a finding under advisement? *
On suspension (academic or honor) at any college or university? *
If you answered yes to any of the above questions, you are required to provide a detailed explanation of each
occurrence, including date and disposition, and any comments you have below:
I agree
I agree
Yes
Yes
No
No
No
No
Yes
Yes
Disciplinary Action Form
1
• This for
m must be completed if you are claiming entitlement to in-state tuition benefits pursuant to Section 23-7.4 of the Code of Virginia.
• Supporting documents and additional information may be requested.
• You MUST complete, sign, and submit this form before the first day of classes of the term for which you are applying
.
• All questio
ns must be answered. Incomplete/unsigned applications will experience delay in processing.
Term for which you are applying for Virginia Status: Fall Spring Summer Year: 20______
Application Status: First application for Virginia Instate Tuition
Applying to be reclassified
N
ame:
(L
ast Name, First Name, Middle Name or Initial)
Date of Birth: __________ University ID Number: ________________________ Social Security Number: _________________________
(if known) (optional – for Federal reporting purposes)
Email Address: _____________________________ Daytime Phone
: ________________________
CURRENT ADDRESS
From (mm/yy): ________ Street Address: _____________________________________________________________________________
To (mm/yy) _________ City, State, Zip ______________________________________________________________________________
Countr
y __________________________________________
PREVIOUS ADDRESS
(Only necessary if you have lived at your current address less than two years.)
From (mm/yy): ________ Street Address: _____________________________________________________________________________
To (mm/yy) _________ City, State, Zip _____________________________________________________________________________
Country __________________________________________
1.
How long have you lived in Virginia? More than 365 days Less than 365 days
If Less than 365 Days . . .
STOP!
. . .
You are NOT eligible for Virginia in-state tuition .
Please sign and date below and return form to the Office of the Registrar.
If 365 days or more . . . Continue to Question 2.
2. Do you (the student) wish to claim in-state tuition rates based on your residency status in Virginia?
YES . . . Continue to Question 3.
NO . . .
STOP!
. . . Please sign and date below, and return form to the Office of the Registrar.
By answering “NO,” you are choosing not to apply for in-state tuition rates and will be charged out-of-state tuition.
3. Citizenship: U.S. Permanent Resident Non-U.S. Citizen
If non-U.S. citizen, please specify Visa Type _________ Exp. Date ___________ ( please provide copy of I-94)
4. Are you (the student) a non-U.S. citizen with one of the following visa classifications: F-1, J-1, or Undocumented (no visa and not a
U.S. citize
n or permanent resident)?
YES . . . STOP! You are NOT eligible for Virginia in-state tuition privileges. Please sign below and return form.
NO . . . Continue to Question 4.
5. Are you (the student) a military dependent or are you on active duty with the military
?
NO . . . Continue to Section B.
YES . . .STOP! Please sign, date, and return this form along with the Active Duty OR Military Dependent Tuition Benefit Forms you
will find at the link below. Return all forms with requested documentation. Your tuition status will be determined based upon the
information you provide. Until then, your account will display out-of-state tuition rates.
http://www.odu.edu/ao/registrar/instate/military/index.shtml
Return To
: Office of the University Registrar
Old Dominion University
116 Rollins Hall, Norfolk, VA 23529
FAX: 757-683-5357 Phone: 757-683-4425
Email: instate@odu.edu
SECTION A: APPLICANT (you, the student)
Application for
Virginia In-State Tuition
2
Continue to page 2
1. Will you be age 24 or older before the first day of classes? Yes No
2. A
re you a veteran of the U.S. Armed Forces? Yes
No
3. W
ill you be enrolled in a graduate or professional program (beyond a Bachelor’s degree)? Yes
No
4. Are you married? Yes No
5. Are you an orphan or a ward of the court, or were you a ward of the court until age 18? Yes No
6. Do
you have any legal dependents (other than a spouse)? Yes
No
7. Did you file an individual Federal tax return last year (no one claimed you as a dependent)? Yes No
If you answered Yes to any question, go to Section C and complete for yourself.
If you answered No to every question . . . STOP . . . sign below and have your parent or legal guardian complete Sections C and D.
Who is completing Section C?
Check One
:
Applicant: Parent Spouse Legal Guardian (please attach proof of legal guardianship)
1. Name: __________________________________________________________________________________________________________
Last First Middle
2. Citizenship:
U.S. Non-U.S. If non-U.S., give visa type: _________________________________________________________
3. How long have you lived in Virginia?
Greater than 365 days Less than 365 days
4. Where have you lived in the last two years?
CURRENT ADDRESS
From (mm/yy): ________ Street Address: _____________________________________________________________________________
To (mm/yy) _________ City, State, Zip ______________________________________________________________________________
Country __________________________________________
PREVIOUS ADDRESS
(Required if you have lived at your current address less than two years.)
From (mm/yy): ________ Street Address: _____________________________________________________________________________
To (mm/yy) _________ City, State, Zip _____________________________________________________________________________
Country __________________________________________
5. Do you have the present intention to remain indefinitely in Virginia?
Yes No
6. Will you have filed a tax return and paid income taxes to Virginia during the last 12 months?
Yes No
7 . Do you have a valid Virginia driver’s license? Yes No
If Yes, will you have held that license for the entire 12 months prior to the first day of applicant’s classes? Yes No
8.Are you a registered Virginia voter?
Yes No
If Yes, will you have been a registered VA voter for the entire 12 months prior to the first day of applicant’s classes? Yes No
9. Do you own a motor vehicle that is registered in the state of Virginia?
Yes No
If Yes, will you have owned this vehicle for the entire 12 months prior to the first day of applicant’s classes?
Yes No
Questions 10 and 11 are for the Parent, Spouse or Legal Guardian
10. Will you have claimed the applicant as a dependent on your federal and Virginia income taxes during the last 12 months? Yes No
11. Will you have provided over half of the applicant’s financial support during the last 12 months?
Yes No
The applicant must sign below. If Section C has been completed by a parent, spouse or legal guardian that person must also sign
below. To “sign” this document electronically, click the signature field and enter your name and the date you are completing the
form. Using this method is considered the same as your handwritten signature. You may also enter a digital signature if you have
one.
I certify under penalty of disciplinary action that the information I have provided is true.
Signature of Applicant (student) Date
Signature of Parent, Spouse, or Legal Guardian Date
(October 2009)
Section B: STUDENT STATUS
Section C: RESIDENCY
Section D: SIGNATURES
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Form modified 3272015: Graduate Reactivation (Old Dominion University)

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Completed 23 July 2020

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