OFFICE USE ONLY
Resident ______ Non-Resident ______ Approved By ____________________________
Date Received ____________ Date Notified ____________ Notified By _______ Email ____ Phone ____
Pending Additional Information ___________________ Appeal _______ By/Date_______________________ /___________
Additional information is needed to determine your residency status. Complete, print, and sign this form then return it with
your supporting documentation to the Gateway Community & Technical College Registrar, 790 Thomas More Parkway,
Edgewood KY 41017. If you have any questions, please contact us at (855) 346-4282 or email@example.com
Please complete all fields. Any fields that do not apply, mark with “N/A” or leave blank. Incomplete forms will not be processed
First Name: ________________________ Middle:______________________ Last: _________________________________
Student ID:______________________ Date of Birth:___________________________
Are you a U.S. citizen?
_____ If yes, what is your citizenship status? __
If not a U.S. citizen, what is your visa type?
When did your present stay in the State of Kentucky begin? ______________________________________________________
What was your reason for coming to Kentucky? ________________________________________________________________
How long have you continuously lived in Kentucky? _____________________________________________________________
When did you last file a Kentucky income tax return? ___________________________________________________________
What term are you applying for:
Are you currently active duty military, stationed in Kentucky?
Are you a spouse or dependent of active military personnel, stationed in Kentucky?
If yes, list the name of the person and your relationship to him/her:
* Military ID and copy of the sponsor’s orders to Kentucky military base are required.
Did you graduate from a Kentucky high school?
Name of high school: _______________________________________________________
Have you attended any other college, university or private high school in the past three years?
If yes, complete the following section: