UNIVERSITY OF PITTSBURGH

AT TITUSVILLE

504 East Main Street, Titusville, PA  16354    Phone:  814-827-4400

APPLICANT DATA FORM

Please answer each and every question that applies to you.  This form is used to determine a student's residency for the purpose of in-state and out-of-state billing.  Questions left unanswered could result in an out-of-state classification.

Name: (Last, First, Middle Initial) ______________________________________________________
Permanent Address: (Street) ______________________________________________________
         (City, State, Zip code) ______________________________________________________
ID#_________________________ Social Security # ___________________ E-mail Address:_______________
Home Telephone:  (            ) __________________ Date of Birth:  ____________
Work Telephone (optional):  (          ) __________________          Gender:     Male     Female
Citizenship: U.S. Citizen Refugee U.S. Immigrant, Permanent Resident Non-Immigrant Student, Visitor

 

  
Ethnicity:  American Indian/Alaskan Native  Black  Asian  White  Pacific Islander  Hispanic

Residency Classification:

Is your Father a resident of Pennsylvania?  Yes, Yrs.__________ Mo._________  No
Is your Mother a resident of Pennsylvania?  Yes, Yrs.__________ Mo._________  No
Is your Guardian a resident of Pennsylvania?  Yes, Yrs.__________ Mo._________  No
Are you a resident of Pennsylvania?  Yes, Yrs.__________ Mo._________  No

I certify that the information provided is true and correct.  I understand that falsification of any data may result in dismissal.  I authorize any employer, educational institution, or agency to release such data as is required by the University to verify any of the above information.

 

Signature____________________________________  Date___________________