Fillable REQUEST FOR REACTIVATION OF APPLICATION for Undergraduate Admission (Virginia Commonwealth University)

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REQUEST FOR REACTIVATION OF APPLICATION for Undergraduate Admission (Virginia Commonwealth University)

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Office of Admissions • 821 West Franklin Street • Box 842526 • Richmond, VA 23284-2526 • www.vcu.edu/admissions
Name
last first middle initial former/maiden name
Permanent address
City State ZIP
If Virginia, county of residence Date of birth
Cell phone number Email
Citizenship ❏ U.S. citizen ❏ Permanent resident alien, political asylum or refugee:
❏ Non-U.S. citizen Resident alien card number A –
– –
❏ Student (F or J) visa Date issued / /
❏ Other than F or J visa (Attach a copy of both sides of your alien registration card, Form I-551
or a copy of your passport stamped “Processed for I-551.”)
Country of citizenship
If other, please specify visa type.
Number of years resided in the U.S.
Is English your native language (regardless of citizenship)? ❏ Yes ❏ No; native language:
Semester and year of entry ❏ Fall Freshman deadline Jan. 15; transfer deadline March 15
year
❏Spring Freshman and transfer deadline Nov. 1
year
Note: All deadlines listed above are for application for general admission to the university.
Some program deadlines may vary; check departmental websites for specific program deadlines.
Intended major Advising track/concentration (if applicable)
If applying for the School of the Arts, have you submitted your portfolio or arranged for an audition? ❏ Yes ❏ No
Have you attended any other college or institution since applying to VCU? ❏ Yes ❏ No If yes, complete below and please submit an official
copy of your transcripts.
Institution name(s)
❏ Fall ❏ Spring Year
Total attempted credit hours Through which semester will you be enrolled?
Have you attended VCU since last applying? ❏ Yes ❏ No
As a special student for these terms? ❏ Fall ❏ Spring ❏ Summer
Total credit hours
Have you ever been dismissed, suspended or asked to discontinue school? ❏ Yes ❏ No
If yes, date of suspension: month/year
/ Are you eligible to return? ❏ Yes ❏ No
If yes, date eligible to return: month/year
/ Please attach explanation.
Are you a veteran of the U.S. Armed Forces? ❏ Yes ❏ No
Are you going to receive Veterans Affairs educational assistance benefits? ❏ Yes ❏ No
Certification
I hereby certify that I have read the instructions for applying to VCU and that the information submitted by me on or with the application is complete and accurate. I also
understand that falsification or failure to provide information requested may result in my immediate dismissal or loss of all credit from the university. My signature is my
guarantee that, should I enroll, I agree to abide by all rules and policies, including the Honor System, of Virginia Commonwealth University. Please note: While you will work
with academic advisers at VCU, submission of this application for admission serves as acknowledgment that you assume the responsibility for satisfying the university
requirements for any VCU degree that you pursue.
Signature Date
Have you ever been convicted of a felony? ❏ Yes ❏ No
If yes, please attach on a separate sheet the date(s) of each convic-
tion and an explanation for each occurrence.
REQUEST FOR REACTIVATION OF APPLICATION
for Undergraduate Admission
Office of Admissions • 821 W. Franklin St. • Box 842526 • Richmond, VA 23284-2526
APPLICATION FOR VIRGINIA IN-STATE TUITION
Completion of this form is required by the commonwealth of Virginia if you are claiming entitlement to Virginia in-state tuition rates pursuant to Section 23.1-502 Code of Virginia.
All questions must be answered. When not applicable, mark the N/A box. Section A must be completed by the applicant. Section B of this form must be completed by the parent/
legal guardian or spouse if the applicant is a dependent. Supporting documents and additional information may be requested. Return this form with your application for admission.
If this form is not submitted, you will be classified as a non-Virginia resident.
Section A - Applicant
(Please Note: While this information is not required for admission consideration, it is necessary for applicants who wish to be considered for financial aid and Hope Scholarship/Lifetime Learning tax credit
to provide a Social Security number to the university.) To protect your privacy, your Social Security number will not be used as your student identification number.
1. Name
_______________________________________________________________________________________ 2. Date of Birth ___ ___-___ ___-___ ___
3. Citizenship
U.S. Permanent resident alien, political asylum or refugee Non-U.S. If non-U.S., give visa type _______________________________________
4. Where have you lived in the past two years? (List current address first. Include dates.)
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Street address City State ZIP Code From (MM/DD/YY) To (MM/DD/YY)
5. Students under the age of 24 are presumed to be dependent on a parent or legal guardian unless
one of the following applies? (Place a check mark beside all that apply.)
Age 24 or older as of the first day of the semester in which you intend to enroll
Veteran or active duty member of the U.S. Armed Forces
Graduate or professional student
Ward of the court or was a ward of the court until age 18
Both parents are deceased, no adoptive or legal guardian
Legal dependents other than a spouse
Independent student (attach federal and state tax forms)
Married
6. Do your parents or legal guardian provide over half of your financial support or claim you as a tax
dependent? Yes No N/A
7. If you are married, do you wish to claim eligibility for in-state tuition rates based on your
spouse’s domicile? Yes No N/A
If Yes, does your spouse provide more than 50 percent of your financial support?
Yes No N/A
If “Yes” to either No. 7 or 8, Section B must be completed by a parent/legal guardian or spouse.
8. Will you have filed a tax return or paid income taxes to any state other than Virginia during the
past year? Yes No N/A
If yes, which state(s)?_________________________________
9. For at least one year prior to the semester in which you will enroll,
will you have:
a. Filed a tax return or paid income taxes to Virginia on all earned income?
Yes No N/A
b. Been a registered voter in Virginia? Yes No N/A
c. Held a valid Virginia driver’s license? Yes No N/A
10. Do you own or operate a motor vehicle? Yes No N/A
If “Yes,” has it been registered in any state other than Virginia during the past year?
Yes No N/A
11. Are you a member of the U.S. Armed Forces? Yes No N/A
If No, go to No. 13.
a. Have income taxes been paid to Virginia on all military income for the last year?
Yes No N/A
If No, have income taxes been paid to another state? Yes No N/A
b. Does the current Leave/Earnings Statement reflect Virginia withholding?
Yes No N/A
If Yes, effective date of change to Virginia: ____________________________________
(Attach a copy of your LES and DD-2058.)
12. Is your parent/legal guardian or spouse a member of the U.S. Armed Forces?
Yes No N/A
If No, go to No. 14.
a. Have income taxes been paid to Virginia on all military income for the last year?
Yes No N/A
If No, have income taxes been paid to another state? Yes No N/A
b. Does the current Leave/Earnings Statement reflect Virginia withholding?
Yes No N/A
If Yes, effective date of change to Virginia: ______________________________________
(Attach a copy of your LES and DD-2058.)
c. Has your parent/legal guardian or spouse claimed you as a dependent for federal and state
income taxes? Yes No N/A
13. Is your parent/legal guardian or spouse a retired military member, who currently resides in
Virginia and resided in Virginia at the time of their retirement?
Yes No N/A
If No, go to No. 15. If Yes, effective date of change to Virginia: ________________________
(Attach a copy of your LES and DD-2058.)
14. If your spouse is in the military, will you have:
a. Resided in Virginia for the past year? Yes No N/A
b. Paid income taxes to Virginia on all earned income? Yes No N/A
15. If your parent/legal guardian is in the military, will the nonmilitary parent/legal guardian have:
a. Resided in Virginia for the past year? Yes No N/A
b. Paid income taxes to Virginia on all earned income? Yes No N/A
c. Claimed you as a dependent for federal and state income tax purposes?
Yes No N/A
16. If you have lived outside Virginia for the past year, will you have:
a. Paid Virginia income taxes on all taxable income earned in Virginia during the past year?
Yes No N/A
b. Lived in a contiguous state to Virginia? Yes No N/A
17. If your parent/legal guardian or spouse has lived outside Virginia for the past year, will the
parent/legal guardian or spouse have:
a. Paid Virginia income taxes on all taxable income earned in Virginia during the past year?
Yes No N/A
b. Lived in a contiguous state to Virginia? Yes No N/A
c. Claimed you as a dependent for federal and state income tax purposes?
Yes No N/A
I certify that all of the information I provided in this application is true and accurate. I understand that this application is a legally binding document and that if I provide fraudulent information, I may be
subject to repayment of tuition or dismissal. I agree to furnish the university with supporting documentation related to my application, if I am requested to do so.
Signature of applicant (required)
_________________________________________________________________________________ Date _______________________________________
Last First M.I. Other (Last Name)
For office
use only.
Term
R N
Records and Registration use only
Date _____________Initials_________
Office of Admissions • 821 West Franklin Street • Box 842526 • Richmond, VA 23284-2526 • www.vcu.edu/admissions
Section B - Parent(s) or Legal Guardian
If your parents/legal guardian or spouse provide over half of your financial support or claim you as a dependent, they must complete this section.
1. Name
_____________________________________________________________________________________________________________________________________________
2. Relationship to applicant: Father Mother Legal Guardian Spouse
3. Citizenship
U.S. Permanent resident alien, political asylum or refugee Non-U.S. If non-U.S., give visa type ___________________________________________________________
4. Where have you lived in the past two years? (List current address first. Include dates.)
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Street address City State ZIP Code From (MM/DD/YY) To (MM/DD/YY)
5. Will you have claimed the applicant as a dependent on your federal and state income tax returns
for the tax year prior to the semester in which the applicant will enroll?
Yes No N/A
6. Will you have provided over half of the applicant’s financial support for at least one year prior to
the semester in which the applicant will enroll?
Yes No N/A
7. Will you have filed a tax return or paid income taxes to any state other than Virginia during the
past year?
Yes No N/A
If yes, which state(s)? _____________________________________________________
8. For at least one year prior to the semester in which the applicant will enroll,
will you have:
a. Filed a tax return or paid income taxes to Virginia on all earned income?
Yes No N/A
b. Been a registered voter in Virginia?
Yes No N/A
c. Held a valid Virginia driver’s license?
Yes No N/A
9. Do you own or operate a motor vehicle?
Yes No N/A
If Yes, has it been registered in any state other than Virginia during the past year?
Yes No N/A
I certify that all of the information I provided in this application is true and accurate. I understand that this application is a legally binding document and that if I provide fraudulent information, the applicant
may be subject to repayment of tuition or dismissal. I agree to furnish the university with supporting documentation related to this application, if I am requested to do so.
Signature of parent/legal guardian or spouse (required)
________________________________________________________________________ Date _______________________________
10. Are you a member of the U.S. Armed Forces?
Yes No N/A
If No, go to No. 11
a. Have income taxes been paid to Virginia on all military income for the last year?
Yes No N/A
If No, have income taxes been paid to another state?
Yes No N/A
b. Does the current Leave/Earnings Statement reflect Virginia withholding?
Yes No N/A
If Yes, effective date of change to Virginia: _____________________________________
(Attach a copy of your LES and DD-2058.)
11. Are you a retired military member, who currently resides in Virginia and resided
in Virginia at the time of your retirement?
Yes No N/A
If Yes, effective date of change to Virginia: _____________________________________
(Attach a copy of your LES and DD-2058.)
Last First M.I. Other (Last Name)
Records and Registration use only
Date _____________Initials_________
Office of Admissions • 821 West Franklin Street • Box 842526 • Richmond, VA 23284-2526 • www.vcu.edu/admissions
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REQUEST FOR REACTIVATION OF APPLICATION for Undergraduate Admission (Virginia Commonwealth University)

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Completed 24 July 2020

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