STUDENT & ELIGIBILITY INFO
Please provide me with a copy of my student records or information about my enrollment at Berkshire Community College as indicated below:
Student Name
LAST FIRST M FORMER
Student ID Date of Birth
Mailing Address
STREET/PO BOX CITY STATE ZIP CODE
Are you a U.S. Citizen? Yes No If not, please complete the following:
Are you a permanent resident?
Yes No If yes, list alien registration number:
If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:
Please check the in-state or reduced tuition eligibility category that applies to you:
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 with 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
Valid Car Registration
Mass. High School Diploma
Record of parents’ residency for unemancipated person*
In-State Tuition Eligibility Form
MASSACHUSETTS COMMUNITY COLLEGES (Please type or print)
Berkshire Community College ▪ 1350 West Street, Pittseld, MA 01201 ▪ www.berkshirecc.edu ▪ 413-499-4660 
Revised 4/13/2020
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS BOX
I have reviewed the above informaon in order to determine this individual’s eligibility to receive the in-state tuion 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 College Personnel Date
Utility bills*
Voter registration*
Signed lease or rent receipt*
Employment pay stub*
State/Federal tax returns*
Military home of record*
Other
CERTIFICATION INFO
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.
Applicant Signature Date
Parent/Guardian Signature Date
(Applicant is under 18 years old)
click to sign
signature
click to edit
click to sign
signature
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