Revised: 7/18/2019 RO Registration Form
OFFICE USE
entered:_____________________ Initials:______ Advisor initials: _____
Student Affairs
PO Box 97, 303 Lowe St, Valdez, AK 99686
Phone 907-834-1632
REGISTRATION FORM
Full Legal Name _________________________________________________________________________________________________
(Last Name) (First Name) (Middle Name)
Previous Names_______________________________________ Gender: Male Female Do not identify as male or female
Social Security Number (required for new students) or UA ID # _________________________________ Date of Birth _____________
(MM/DD/YYYY)
Mailing Address _________________________________________________________________________________________________
Phone Number __________________________________ Preferred E-mail address: _______________________________________
Citizenship Status: Are you a U.S. citizen? Yes No If you are not a U.S. Citizen, what is your current immigration status? ____________________
You must submit documentation of your immigration status to Student Services.
Residency: Are you qualified to receive an Alaska Permanent Fund Dividend? Yes No
Eligibility for an AK Permanent Fund Dividend is used to determine residency. I understand I may be requested to provide documentation to verify eligibility.
Ethnic category What is your ethnicity? Not Hispanic or Latino Hispanic or Latino
Ethnic Origin: Please indicate which, if any of the following races you consider yourself to be. You may mark more than one.
The University is collecting this information as required by federal regulation in reporting races and ethnicity for employment and educational statistics.
__ Alaska Eskimo other/unspecified (AE)
__ Alaska Indian other/unspecified (AI)
__ Alaska Native other (AN)
__ Alaska Native Southeast (AS)
__ Aleut/Unangax (AA)
__ Alutiiq/Sugpiaq (AL)
__ American Indian (IN)
__ American Indian and Black (IB)
__ American Indian and White (IW)
__ American Indian or AK Native (XX)
__ Asian (SI)
__ Asian other (SO)
__ Asian and White (AW)
__ Asian/Pacific Islander (PI)
__ Black and White (BW)
__ Black or African American (BL)
__ Chinese (SC)
__ Cup’ik (AC)
__ Dené/Athabascan Ahtna (DA)
__ Dené/Athabascan Deg Xinag (DX)
__ Dené/Athabascan Dena’ina (DD)
__ Dené/Athabascan Gwich’in (DG)
__ Dené/Athabascan Han (DG)
__ Dené/Athabascan Holikachuk (DO)
__ Dené/Athabascan Koyukon (DK)
__ Dené/Athabascan Lower Tanana (DL)
__ Dené/Athabascan Tanacross (DT)
__ Dené/Athabascan Upper Kuskokwim (DW)
__ Dené/Athabascan Upper Tanana (DU)
__ Dené/Athabascan (AT)
__ Eyak (AJ)
__ Filipino (SC)
__ First Nations (FN)
__ Guamanian (SG)
__ Haida (AH)
__ Hispanic other (HI)
__ Indian (Asian subcontinent) (SN)
__ Indigenous other (IO)
__ International Indigenous (II)
__ Inupiaq (AQ)
__ Japanese (SJ)
__ Native Hawaiian (SH)
__ Native Hawaiian or other Pacific Islander (NH)
__ Not Specified (UN)
__ Other (OT)
__ Other Indigenous Pacific Islander (IP)
__ Pacific Islander other (SP)
__ Samoan (SR)
__ Siberian Yupik (AO)
__ Student Refused (SR)
__ Tlingit (AK)
__ Tsimshian (AM)
__ Vietnamese (SV)
__ White( WH)
__ Yup’ik (AY)
Please choose one semester: Fall 20 ______ Spring 20 ______ Summer 20______
I understand that by signing I am responsible for tuition and fees associated with any course(s) for which I have registered. I am
responsible for dropping courses by published deadlines to ensure charges are not incurred. I understand that if I default on this
student account, I am responsible for the collection, attorney and legal fees. The University may garnish my Alaska Permanent
Fund Dividend under Alaska Statutes 14.40.251 and 43.23.073. I also understand that the past due debt may be reported to credit
bureaus.
Student’s Signature: __________________________________________________ Date: ________________________
CRN
Subject
Course #
Section
Course Title
Credit/Audit
Instructor’s Signature
Date
Received
Office use only
click to sign
signature
click to edit
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