Carbon
Lehigh
is not
s
2. Student (F1)____________ 3. Permanent Resident: Alien Card No.
____
Box 3, and complete the ne
__________ Year__________
udent Name____________________________________________
Summer
St
St
Number
State________ Zip
State________ Zip
State________ Zip
State________ Zip
State________ Zip
State________ Zip
: Month
2, or
________
____
Upon review of the above data, I hereby declare the above name
d
d
eligible for residence status in this school district.
eligible for residence status in this school district.
eligible for residence status in this school district.
eligible for residence status in this school district.
_____________________________________________________________________________________________________________________________________
Complete this form and bring to
Business Office
.
State
ment of Residency
L
EHIGH CARBON COMMUNITY COLLEGE
4525 Education Park Drive
Schnecksville, PA 18078-2598
Semester: Fall
__________
Spring
__________
__________
FOR OFFICE USE ONLY
Entered in Banner:
Date
__________________
Initials
________________
udent Name____________________________________________St
udent Name____________________________________________
Social Security Number_______________________Age
______
Stree
t Address_______________________________________________________Telephone
_________________________
City______________________________________Count
y
State________ Zip
___________________
Northampton
Other
Date moved to this address
: Month__________ Year__________ Month
__________ Year__________
(If at this address less than one year, please show previous address below.)
Street______________________________________________City____________________________State________Z
ip
__________
How long at this address?_____________________________________
Each registrant is required to file a Statement of Residency for the purpose of determining school district jurisdiction. The information
given is subject to verification, and falsification may result in additional fees and cost which if not paid will result in cancellation of
registration.
Please check either Box 1, Bo
x
2, or Box 3, and complete the ne2, or
Box 3, and complete the ne
cessary information.
1. Resident of Sponsoring School District: Please read the following list carefully and check the school district in which you reside.
(L) Lehighton
(N) Northern Lehigh
(R) Northwestern Lehigh
(P) Palmerton
(V) Panther Valley
(K) Parkland
(S) Salisbury
(U) Southern Lehigh
(W) Whitehall-Coplay
(A) Allentown
(C) Catasauqua
(E) East Penn
(T) Jim Thorpe
2.
Resident of Nonsponsoring School District. If a Pennsylvania resident, list the County
________________________________
3.
Nonresident of Pennsylvania / International Student
4.
Resident of Schuylkill County
5. I am a citizen of the United States.
Yes
No
If no, please indicate Country of Citizenship
_________________________
Type of VISA:
1. Visitor
____________________
____ 2. Student (F1)____________ 3. Permanent Resident: Alien Card No.____
2. Student (F1)____________ 3. Permanent Resident: Alien Card No.
____________________________
6. Do you have
a drivers license?
Yes
No
If
yes,
give exact address on license______________________________________________________
Check if same as above
PLEASE SIGN THE FOLLOWING STATEMENT:
This is to certify that the information stated above is true and correct
.
DATE____________________________________STUDENT’S SIGNATURE___________________________________________
Upon review of the above data, I hereby declare the above name
sd
s
tudent
is
eligible for residence status in this school district.
Upon review of the above data, I hereby declare the above name
eligible for residence status in this school district.
is not
eligible for residence status in this school district.
is not
Date Secretary/Business Manager Official Seal
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