REGIONAL RESIDENCY FORM
IN-STATE TUITION STATUS graduate students only *
_____________________________________________________________________________________________________________
1. Do you possess a valid driver’s license or identification card? Yes No
a. If yes, date of issue: __________ in what state: _____________
2. Do you own any motor vehicles? Yes No
a. If yes, initial date of registration (mm/yyyy): _________ in what state: ___________
b. Most recent date of registration (mm/yyyy): _________ in what state: ___________
3. Are you registered to vote? Yes No
a. If yes, in what state? __________ Date of registration: ___________
4. Were you previously registered to vote in another state? Yes No
a. If yes, what state? ____________
I certify that the information provided is complete and correct. I understand that the university reserves the right to request
additional information if necessary. In the event the university discovers that false or misleading information has been
provided, the student applicant may be billed by the university retroactively to recover the difference between in-state and
out-of-state tuition for the current and subsequent semesters.
SIGNATURE OF APPLICANT: ______________________________________________________DATE: ___________
SIGNATURE OF PARENT (if applicant is under the age of 18): ______________________________ DATE: ___________
JEANNE CLERY DISCLOSURE OF CAMPUS SECURITY POLICY AND CAMPUS CRIME STATISTICS ACT QUESTIONS
The following questions are required by federal law. If you answer “yes” to any of them, please attach a letter of
explanation addressing in detail the nature of the incident, when it occurred and its resolution.
a. Have you ever been convicted of a crime, other than a minor traffic violation, for which the charges have not been
expunged or pardoned? Yes No
b. Have you ever been academically dismissed from or declared ineligible to attend any previous institution, including
the University of Baltimore? Yes No
c. Has disciplinary action been initiated or taken against you at any of the institutions you previously attended,
including the University of Baltimore? Yes No
I certify that the information provided is true and complete to the best of my knowledge. If it is not, I understand that
cancellation of my class registration my result.
SIGNATURE OF APPLICANT: ________________________________________ DATE: ____________________________
SIGNATURE OF PARENT (if applicant is under the age of 18): ______________________________ DATE: ___________
The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act requires that colleges and universities publish and
distribute an annual security report. You may view and download this document by visiting www.ubalt.edu/ubpolice.
Nondiscrimination policy: The University of Baltimore (“UB” or “University”) does not discriminate on the basis of sex, gender, race,
religion, age, disability, national origin, ethnicity, sexual orientation, gender identity or other legally protected characteristics in its
programs, activities or employment practices. Inquiries regarding discrimination related to educational programs and activities should be
directed to the Title IX coordinator, Anita Harewood, vice president, Office of Government and Community Relations, Academic Center,
Room 336, phone: 410.837.4533, T9@ubalt.edu; dean of students, Office of Community Life, Academic Center, Room 112, phone:
410.837.4755, communitylife@ubalt.edu; or assistant vice president, Office of Human Resources, Charles Royal Building, Third Floor,
410.837.5410, mmaher@ubalt.edu. This includes inquiries regarding Title IX of the Education Amendments of 1972 as amended (“Title
IX”) and Section 504 of the Rehabilitation Act of 1973.
