Application and Affidavit
For Eligible New Jersey High School Graduates
Complete and sign this form to request in-state tuition pursuant to P.L. 2013, C. 170 (“Dream Act”).
Inquiries and submission of application and affidavit are to be made to:
New students: Office of Admissions, 2039 Kennedy Blvd, Hepburn Hall, Room 207
Jersey City, New Jersey 07305 201-200-3234 Email: Admissions@njcu.edu
Continuing students: Registrar’s Office, 2039 Kennedy Blvd, Hepburn Hall, Room 214
Jersey City, New Jersey 07305 201-200-3143 Email: Registrar@njcu.edu
If you are determined to be eligible, you will continue to receive exemption from non-resident tuition status as long as you fulfill the
requirements or the University no longer offers this exemption, whichever occurs first. Applying for the exemption does not in any
way alter your responsibility to pay on time any tuition and fees that may be due before eligibility is determined. You must complete
all sections of this form.
I, the undersigned, am applying for an exemption to obtain in-state tuition status and declare that all of the following apply to me:
1. I have attended high school in New Jersey for three or more years; and
2. I have graduated from a New Jersey high school or have attained the equivalent of a high school diploma
in New Jersey; and
3. I am a non-citizen without a current valid visa.
Provide information on all schools you attended in grades 9-12:
High School City State From Month/Year To Month/Year
NOTE: You must submit this Affidavit with your official high school transcript(s) including all courses and grades to date. If you
have already graduated from high school, you must submit your final official high school transcript.
By signing this document, I hereby state that if I am a non-citizen without lawful immigration status
o I have filed an application to legalize my immigration status or
o I will file an application as soon as I am eligible to do so
I, the undersigned, declare that the information I have provided on this form is true and accurate. I understand that this information
will be used to determine my eligibility for in-state tuition. I further understand that if any of the above information is found to be
false, I will be liable for payment of all charges from which I was exempted and may be subject to disciplinary action by the
Print Full Name (as it appears on your application)
NJCU Identification Number
Print Full Permanent Address
E-mail Address