VENTURA COUNTY COMMUNITY COLLEGE DISTRICT – ADMISSIONS & RECORDS
Moorpark College Oxnard College Ventura College
Military Residency Statement
(Statement of military person claiming residency or person recently separated from the military)
Legal Name _________________________________________________________________________________________________
Rate/Rank Last First Middle Maiden
Sex
Male Female Date of Birth ____________________ Date Entered Service__________________________
month/day/year month/day/year
Branch of Service ___________________________________________ Telephone Number ___________________________
Present Address _____________________________________________________________________________________________
Street City State Zip
Legal Resident for state income tax purposes:
_________________________________________________________________ Effective Date _______________________
Street City State Zip
Home of Record as shown on military records:
_________________________________________________________________ Effective Date _______________________
Street City State Zip
Date of military assignment to California __________________________________________________________________________
Commanding Officer’s/Unit Personnel Officer’s Declaration: I hereby declare under penalty of perjury that the above statements
are true and correct, and that the person named above has not been assigned to active duty in California for educational purposes.
Signature _____________________________________ Date __________________ Executed at _______________________
Commanding Officer or Unit Personnel Officer State of California
Student’s Declaration: I hereby declare under penalty of perjury that above statements are true and correct. I understand that any
misrepresentation will result in my immediate dismissal.
Signature _____________________________________ Date ___________________ Executed at _______________________
Student Sate of California
