OFFICE OF THE REGISTRAR
MSC 105, 700 UNIVERSITY BLVD., KINGSVILLE, TEXAS 78363-8202
(361) 593-2811 • FAX (361) 593-2195 • www.tamuk.edu
MILITARY RESIDENCY DECLARATION
Personal Information
Student’s Last Name First Name Middle Name SS#
Local Mailing Address
Telephone Number My Military Identification Card Number
“ I affirm that I am currently a dependent of a member of an active U.S. military unit stationed in
Texas
Name of Military Member SS# of Military Member Relationship to Student
Military Unit Designation & Mailing Address Unit Telephone
I CERTIFY THAT THIS ABOVE INFORMATION IS TRUE AND CORRECT
Signature of Student Date
PLEASE NOTE THAT OFFICIAL CERTIFICATION BELOW MUST BE PROVIDED:
CERTIFICATION TO BE COMPLETED BY MILITARY UNIT OF ASSIGNMENT
This is to confirm Military Assignment indicated above. I further certify that to the best of my knowledge that same
assignment will be in effect on date member registers at Texas A&M University-Kingsville.
Certification may be awarded for a specified term or terms of an academic year (fall through summer). Please indicate the
term or terms in which this certification will effect:
The scholarship is effective for: Fall Spr Spr Inter_____ SSI SSII Fall Inter_____
Name of Unit Print Name of Commanding Officer
Station Signature of Certifying Officer
A MEMBER OF THE TEXAS A&M UNIVERSITY SYSTEM
