North Carolina Central University
School of Library and Information Science
 
 Residency Form
 
YOU MUST ANSWER ALL QUESTIONS ON THIS FORM PRINT OR TYPE YOUR RESPONSES. FOR ANY INAPPLICABLE QUESTION, WRITE N/A.
 

1.  Full Name____________________________ Social Security Number__________________
2. Age______ Date of Birth____________ Place of Birth___________Citizenship ___________
3. Current Mailing Address______________________________________________________
                                                 Street  Number                                                                      City             State Zip Code
    Until(date)_______________                Telephone Number _____________
4. If you are married: Spouse's Name_______________________ Date of Marriage__________
5. Father Living?   ___ Yes ___ No     His Name _____________________________________
6. Mother Living? ___ Yes ___ No     Her Name _____________________________________
7. If your parents are divorced, whose custody are/were you? ____________________________
8. Name of court-appointed legal guardian(if applicable) ________________________________
9. If you have a court-appointed legal guardian, where (Place) ____________________________
10. Have you, or your spouse, or either of your parents been in active military service within the past
      two years? ___Yes ___ No
11. Check each of the following you have ever done outside North Carolina:
      Attended post-secondary school _____; worked _____

12. Secondary (high or preparatory schools you attended in sequence)
 

School  Address  Date Attended 
     
     
     
13. Are you currently enrolled in college? ____ Yes ____ No
      If Yes, Where? ____________________________________________________________

14. Give the permanent home address. (Street, City, State) of each person listed below.
 

Name of Person Address Date Moved There?
Yours    
Spouse    
Father    
Mother    
Guardian    
 
 
15. If you or your spouse had other N.C. addresses in the past 5 years, give the following
      information for those addresses:
 
  Address (Street, City, State) Lived there from_______ to_______
You    
You    
You    
Spouse    
Spouse    
Spouse    
16. Give the last address outside N.C. (Street, City, State) for each person listed below.
 
  Address (Street, City, State) Lived there from_______ to_______
Your    
Spouse    
Father    
Mother    
Guardian    
17. Are you an Alien? ____ Yes ____ No     If Yes, please list Visa # _____________________
18. Was N.C. State Income Tax filed? ____Yes ____No     What Year? ___________________
       a. Filed state intangible tax return? ____Yes ____ No
       b. Listed personal property for taxation? ____Yes ____ No

IF ADDITIONAL INFORMATION IS NEEDED, THE APPLICANT WILL BE NOTIFIED.

I hereby acknowledge that completion of item 1 (Social Security Number) is voluntary, is required by the institution solely for administrative convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of this institution.

I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution but that the institution may divulge the contents of this application only as permitted under the Family Educational Rights and Privacy Act of 1974 if I am, or have been in attendance at this institution.

_________________________________________________________     _______________
Signature of Applicant  ( Signature of Parent or Guardian if applicant's age is under 18)                     Date