Fillable Last First Middle Initial (Coastal Carolina Community College)

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Last First Middle Initial (Coastal Carolina Community College)

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The Last First Middle Initial (Coastal Carolina Community College) form is 3 pages long and contains:

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  • 18 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Coastal Carolina Community College

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Student’s Name:
Last First Middle Initial
Student ID#: or Last 4 Digits of Social Security #:
COASTAL CAROLINA COMMUNITY COLLEGE
Application for the Benet of the In-State Tuition Rate
as a Dependent Family Member
Under North Carolina General Statues Section (NC G.S. 116-143.3) certain members of the armed
services and their dependent family members may be eligible to be charged the in-state tuition rate
whether or not they qualify as residents for tuition purposes under NC G.S. 116-143.1. The pertinent
law and implementing regulations are available for inspection in the Student Services Office at Coastal
Carolina Community College, and may be examined upon request. Included among the requirements
are that the member of the armed services and a family member claiming the benefit through a member,
be living in North Carolina incident to the supporting member’s active military duty and that the applicant
for the benefit qualify for academic admission at the pertinent institution.
**This application must be submitted prior to initial enrollment in each academic year for
which the in-state rate benet is claimed**
DIRECTIONS
1. Respond to all questions and complete all the questions within the part of the form that applies to you.
2. Print or type all responses. If necessary, write “See Attached” in the space provided, and use an
additional sheet(s), numbering your responses the same as the corresponding question and stapling
these sheets to your application form.
3. Be completely accurate to the best of your knowledge and understanding.
Note: Knowing falsication of your responses may subject you to disciplinary action,
including dismissal from the institution.
4. When a date is requested, please give the day, month and the full year.
5. Sign and date this application where indicated to make those acknowledgements and certications
necessary to render this a viable application.
Please note: The certifying Military Ofcial must be a Staff Non-Commissioned Ofcer, higher
ranking ofcial or designated Family Readiness Ofcer.
6. Turn in complete application to the Admissions Ofce located in the Student Service Center.
7. If you have any questions, please contact the Admissions Ofce at (910) 938-6396.
APPLICATION FOR MILITARY FAMILY MEMBERS
1. Applicant’s full name:
Student ID#/Social Security Number: Date of Birth: / /
2. For the service member through whom you claim the tuition benet, provide the following:
Full Name: Rank:
Last 4 digits of Social Security Number: Date of Birth: / /
Branch of Armed Services:
US Marine Corps US Coast Guard US Army
US Navy US Air Force NC National Guard
Is this a reserve component of the indicated service? YES NO
3. What is the permanent duty station of the above-reference member?
4. What is the street address or building location at which you currently reside?
5. At which institution do you wish the tuition benet to apply? Coastal Carolina Community College
6. Have you been academically admitted to the designated institution? YES
NO
7. Beginning with which academic term are you seeking the tuition benet?
Year Term
8. Do the orders by which the member assigned to active military duty in North Carolina establish a
date on which that duty will cease?
YES NO If YES, what is the date?
9. What is your relationship to the member through whom you claim the tuition benet?
10. Sponsor’s anticipated military separation date (month/day/year):
(Those with an indenite military identication card use expiration date on your military ID card)
CERTIFICATION BY APPROPRIATE MILITARY AUTHORITY
This is to attest that is a military dependent of
Last First Middle Initial
whose active duty station is .
Name of Military Sponsor and Last 4 digits of Social Security Number
Printed Name of Supervising Military Authority Supervising Military Authority Signature
Date
MILITARY FAMILY MEMBERS 18 YEARS OR OLDER
STATEMENT OF REGISTRATION COMPLIANCE
I certify that I am not required to be registered with Selective Service because:
I am a female
I am in the armed services on active
duty
I am a permanent resident of the
Trust Territory or the Northern Mariana
I was born before 1960
I certify that I am registered with the Selective Service
Signature Date
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***I hereby acknowledge that submission of my Student ID# or Social Security Number is requested by the institution solely for administrative
convenience and record-keeping accuracy, and is requested only to provide a personal identier for the internal records of the institution.
***I hereby certify that all information I have set forth herein is true to the best of my knowledge, pursuant to my reasonable inquiry where
needed.
***I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution,
but that the institution may divulge the contents of the application only as permitted under the Family Educational Rights and Privacy Act
(FERPA) of 1974 if I am, or have been, in attendance at the institution.
Applicant Signature Date
Signature of Parent or Guardian (if applicant is under 18 years of age) Date
**BE SURE THAT THE CERTIFICATION BY APPROPRIATE MILITARY AUTHORITY IS COMPLETED**
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Last First Middle Initial (Coastal Carolina Community College)

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Completed 3 February 2021

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