1. No category

WISE?
ARE YOU UVA
APPLICATION FOR ADMISSION
“You can easily get to know everyone on campus. And I’m
talking about from the chancellor down. People here want
to get to know you. You could go knock on the chancellor’s
door and she’d welcome you in.”
— Santana VanDyke
Dear Applicant:
As you complete this application for admission to the University of
Virginia’s College at Wise, you will be asked to think about your educational
goals. For some, they may be no more specific than obtaining a bachelor’s
degree in a yet-to-be decided major. For others, they may involve preparation
for a particular career.
Our goal at UVa-Wise is to give you a liberal-arts foundation that will
serve you well no matter what path you choose to pursue.With programs in
pre-professional studies, teacher education, and a wide range of majors—
from business administration to theatre—UVa-Wise prepares students for
rewarding careers, graduate study, and lifelong learning. Our extracurricular
options also help develop talents, cultivate interests, and provide leadership
experience. With an open mind and motivation to discover your potential,
you will find many options here to explore.
Wishing you every success,
Russell D. Necessary
Vice Chancellor for Enrollment Management and Student Life
APPLICATION INSTRUCTIONS
Application Requirements
All applicants to the University of Virginia’s College at Wise must be
graduates of approved secondary schools or hold certificates of high
school equivalency (GED). Applicants must submit a completed
application, $25 nonrefundable application fee, official high school
transcript, scores for the Scholastic Aptitude Test (SAT I) or American
College Test (ACT), and an official transcript from all colleges
attended, even for one course.
EARLY ADMISSION I
Priority Dates
SAT test scores can be requested at www.collegeboard.org,
UVa-Wise school code 5124. ACT test scores can be requested
at www.actstudent.org, UVa-Wise school code 4343.
• Eligibility for application to Peake Honors Program
Once a student’s application is complete, the information will be
reviewed and the student will be notified of the admissions decision.
EARLY ADMISSION II
Priority Dates
Admission Guidelines
Preference is given to students who have successfully completed the
following criteria:
• Admitted by: February 1
• 4 years of English
• 3 years of mathematics, including Algebra I and II and a third
course to be chosen from geometry, advanced algebra and
trigonometry, calculus, or related course
• 2 or more years of science beyond general science
• 2 or more years of a foreign language
• Rank in the top half of the graduating class
• SAT Reasoning Test score of 900 or better (on mathematics
and critical reading sections) or ACT of 18 or better (waived if
applicant is 25 years of age or over)
Required Documents
Please request that your high school counselor send an official
transcript of all completed course work and your College Entrance
Examination Board scores to the UVa-Wise Office of Admissions,
1 College Avenue, Wise, VA 24293-4412. If your high school
cannot provide your scores, please have them sent by the testing
organization to the Office of Admissions. Students who have earned
a GED in lieu of a high school diploma should submit official
GED scores, an official high school transcript showing years
attended, and (if under 25) SAT or ACT scores. Students who have
attempted 30 or more transferable semester hours of course work
or are 25 years of age or older at time of application are not required
to submit SAT or ACT scores.
Options for Freshman Admission
For students who choose to apply early in their senior year, UVaWise offers two nonbinding early-admission programs. These
programs allow students to take advantage of certain benefits—
including academic scholarships, special registration sessions,
and a broader selection of residence hall options—by following
established timelines. Candidates for Early Admission I should
present a strong record of academic achievement and plan to take
the SAT/ACT no later than October. Completed applications for fall
semester enrollment will be reviewed beginning September 1.
The enrollment deposit of $75.00 is refundable through May 1 for fall
enrollment and December 1 for spring enrollment. Refund requests
should be made in writing and postmarked by the appropriate date.
• Admitted by: December 1
• Enrollment Deposit Due: February 15
Benefits
• Advance course registration beginning in March
• Early academic scholarship and financial aid consideration
• Priority housing selection (based on date of receipt of actual
housing application)
• Enrollment Deposit Due: March 15
Benefits
• Advance course registration beginning in April
• Early academic scholarship and financial aid consideration
• Priority housing selection (based on date of receipt of actual
housing application)
REGULAR ADMISSION
Priority Dates
• Applications received after February 1
• Enrollment Deposit Due: May 1 (Students who choose to apply
after May 1 will be required to submit the enrollment deposit two
weeks after notification of acceptance.)
Benefits
• Advance course registration beginning in June
• Priority financial aid consideration through April 1
• Priority housing selection (based on date of receipt of actual
housing application)
Contacting the Office of Admissions
E-mail: [email protected]
Phone: (888) 282-9324 (toll-free) or (276) 328-0102 (local)
Web: www.uvawise.edu
Fax: (276) 328-0251
CHECKLIST: Application Requirements by Status
SUPPORTING
MATERIAL
Application Fee*
SAT/ACT Scores
High School
Transcript
SAT Code:
5124
ACT Code: 4343
FAFSA Code: 003747
College
Transcript(s)
APPLICANT STATUS
New Freshmen
Students who have not
attended a college or
university or who have
earned college credit
while in high school and
who are under 25.
$25 check or
money order.*
Transfer Students
Undergraduates who
have been enrolled as a
matriculated student at
a college or university.
$25 check or
money order.*
SAT/ACT scores.
SAT/ACT (required only
if less than 30 semester
hours have been
attempted).
Official transcript
(required only if less
than 30 semester hours
have been attempted).
No
Candidate for Readmission
Any student whose
enrollment has been
interrupted for a semester
must be approved for
readmission.
No No
International Students
$25 check or money
order. Supplemental
application will be sent
by admissions office*
SAT/ACT required unless
25 or older.
Nondegree Students**
Nondegree students are
those who wish to take
courses for personal
enrichment rather than
earn a degree through
the College.
No
No
Dual-enrollment
Students**
Students applying to
take courses while still
enrolled in high school are
considered dual-enrollment
students.
No
However, you must submit
letters of consent from a
parent or guardian and
from your high school
principal or guidance
counselor.
Official transcript sent
directly from your
high school.
TOEFL score
SAT/ACT scores required.
Official transcript sent
from each institution
at which you have
been enrolled.
UVa-Wise prefers that
international transcripts
be evaluated by World
Education Services. The
website is www.wes.org
No
Official transcript
required.
Official transcript sent
from each institution
from which you have
earned credit while in
high school.
Official transcript sent
from any institutions at
which you have been
enrolled since your
enrollment here.
UVa-Wise prefers that
international transcripts
be evaluated by World
Education Services. The
website is www.wes.org
No
Official transcript sent
from each institution
from which you have
earned credit while in
high school.
* Application fee waivers are available upon request.
**Nondegree and dual-enrollment students are not admitted to a degree program, not eligible for financial assistance or campus housing, and not assigned an advisor.
OFFICE OF ADMISSIONS
The University of Virginia’s College at Wise
1 College Avenue • Wise, VA 24293-4412
E-mail: [email protected]
Phone: (888) 282-9324 (toll-free)
(276) 328-0102 (local)
Web: www.uvawise.edu
Fax: (276) 328-0251
APPLICATION FOR ADMISSION
PERSONAL INFORMATION
TYPE OF STUDENT (Check one.)
NEW FRESHMAN
NEW FRESHMAN WITH COLLEGE CREDIT
TRANSFER (FROM ANOTHER COLLEGE)
READMISSION (for students previously enrolled in a degree program here)
degree; please submit official transcripts from all colleges attended)
NONDEGREE
TEACHER CERTIFICATION (only for students who have obtained a bachelor’s
DUAL ENROLLMENT (for students applying to take courses while in high school)
NAME (Please print.)
FIRST
MIDDLE LAST
_______________________________________________________________________________________________________________________________________
PREFER TO BE CALLED BIRTH DATE (Month/Day/Year) GENDER: MALE
FEMALE
_______________________________________________________________________________________________________________________________________
SOCIAL SECURITY NUMBER (For reporting purposes only)
_______________________________________________________________________________________________________________________________________
YES
NO
IF YES, MAIDEN NAME?
ARE
YOU MARRIED? _______________________________________________________________________________________________________________________________________
MAILING ADDRESS (Not physical address) APT. NO.
_______________________________________________________________________________________________________________________________________
CITY/STATE COUNTY ZIP CODE
_______________________________________________________________________________________________________________________________________
HOME PHONE (Area code) CELL PHONE (Area code)
_______________________________________________________________________________________________________________________________________
E-MAIL _______________________________________________________________________________________________________________________________________
EMPLOYMENT (If applicable)
COMPANY
NAME WORK PHONE (Area code)
______________________________________________________________________________________________________________________________________
HAVE YOU APPLIED FOR ADMISSION HERE PREVIOUSLY?
HAVE YOU ATTENDED UVA-WISE BEFORE?
YES
DID YOU RECEIVE A DEGREE FROM UVA-WISE?
WHEN DO YOU PLAN TO ENROLL?
YES
NO If yes, when? (Month/Year) _____________________________________________
NO If yes, when? (Month/Year) __________________________________________________________
YES
FALL (August)
NO If yes, check one:
SPRING (January)
WHICH CAMPUS DO YOU PLAN TO ATTEND? (Transfer students only)
B.A.
B.S.
SUMMER SESSION I (June)
WISE CAMPUS (Main)
SUMMER SESSION II (July) YEAR:__________
ABINGDON CAMPUS
CITIZENSHIP STATUS
U.S. CITIZEN
PERMANENT RESIDENT (Please provide copy of both front and back of Form I-551/Green Card.)
NON U. S. CITIZEN VISA TYPE _____________________________________Date of Issuance__________________Date of Expiration___________________
(please include copy of Visa)
ARE YOU A MEMBER OF ANY OF THE FOLLOWING GROUPS? (Optional, for reporting purposes only)
Gear-Up
TalentSearch
TRiO or Upward Bound
Veteran of the U.S. Armed Forces
I am a first generation college student. [Neither parent completed a Bachelor’s (4-year college) degree or higher.]
RACE (Optional, for reporting purposes only)
AFRICAN AMERICAN
NATIVE AMERICAN
ASIAN/PACIFIC ISLANDER
HISPANIC/LATINO
CAUCASIAN
OTHER/UNKNOWN
FIELDS OF STUDY
SELECTING A MAJOR (Please check only one.)
Applicants should select an academic interest area from those listed below. If you are undecided about an area of interest, you may choose “undeclared.”
Indicating an interest area on your Application for Admission is not considered an official declaration of an intended major nor an indication of acceptance
into a specific academic program.
ACCOUNTING
ADMINISTRATION OF JUSTICE
HEALTH AND PHYSICAL EDUCATION
SPORTS MANAGEMENT CONCENTRATION
ART
HISPANIC AND HISPANIC AMERICAN STUDIES
BIOCHEMISTRY
HISTORY
BIOLOGY
INTERDISCIPLINARY STUDIES
BUSINESS ADMINISTRATION
LIBERAL ARTS AND SCIENCES PRE-K–6/SPECIAL ED. PRE-K–12
CHEMISTRY
MANAGEMENT INFORMATION SYSTEMS
COMMUNICATION STUDIES
MATHEMATICS
COMPUTER SCIENCE
MEDICAL TECHNOLOGY
ECONOMICS
MUSIC
ENGLISH LITERATURE
NURSING
ENVIRONMENTAL SCIENCE
PSYCHOLOGY
FOREIGN STUDIES
SOCIOLOGY
FRENCH
SOFTWARE ENGINEERING
GOVERNMENT
SPANISH
HEALTH AND PHYSICAL EDUCATION TEACHER LICENSURE
THEATRE
UNDECLARED
PRE-PROFESSIONAL PREPARATION (Check one if applicable.)
Applicants considering pre-professional study should select a major from the list above as well as one of the pre-professional options below.
Pre-law students often select majors such as government, history, business, or English. Students who select science-related programs, such as
pre-medicine, pre-physical therapy, pre-dentistry, or pre-veterinary science, often choose biology or chemistry as a major. Pre-pharmacy students
should select chemistry as a major.
PRE-LAW
PRE-VETERINARY MEDICINE
PRE-MEDICINE
PRE-PHYSICAL THERAPY
PRE-FORESTRY
PRE-PHARMACY
PRE-ENGINEERING
PRE-DENTISTRY
TEACHER EDUCATION PROGRAMS (Check one if applicable.)
Teacher education students should select a major from the previous list of major programs as well as an intended area of concentration from the
certification options below:
ELEMENTARY EDUCATION PRE-K–6
MUSIC EDUCATION (K-12)
MIDDLE SCHOOL EDUCATION 6–8
INSTRUMENTAL
SECONDARY EDUCATION 6–12
VOCAL/CHORAL
SPECIAL EDUCATION
LIBRARY SCIENCE
PHYSICAL EDUCATION/HEALTH
EDUCATION HISTORY
HIGH SCHOOL
NAME
OF HIGH SCHOOL FROM WHICH YOU DID OR WILL GRADUATE
_______________________________________________________________________________________________________________________________________
CITY/STATE
GRADUATION (Month/Year) or GED (Month/Year)
_______________________________________________________________________________________________________________________________________
WHAT COURSES ARE YOU OR WILL YOU BE TAKING? (Applicable only if you are currently a high school senior)
SEMESTER
1
SEMESTER 2
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
DID YOU TAKE A COLLEGE ENTRANCE EXAM?
YES
NO If yes, check one and indicate test date:
ACT
SAT ______________________________
PREVIOUS COLLEGE WORK (Please list college work you have completed while enrolled in high school.)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
LIST ALL COLLEGES YOU HAVE ATTENDED PREVIOUSLY (IN ORDER OF ATTENDANCE, WITH MOST RECENT FIRST). [This must include any institution
at which you registered for classes (even if a withdrawal was granted) and any at which you will attend classes prior to enrollment at UVa-Wise. Failure to list
colleges or universities you have attended can result in dismissal.]
COLLEGE/UNIVERSITY
CITY/STATE DATES ATTENDED
_______________________________________________________________________________________________________________________________________
COLLEGE/UNIVERSITY
CITY/STATE DATES ATTENDED
_______________________________________________________________________________________________________________________________________
COLLEGE/UNIVERSITY CITY/STATE DATES ATTENDED
_______________________________________________________________________________________________________________________________________
CURRENT COLLEGE WORK (If you are now registered for work at college, please list those courses below.)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
EXTRACURRICULAR ACTIVITIES
PREVIOUS ACTIVITIES
(Please list your participation in extracurricular activities such as clubs, athletics, publications, music, etc., and any recognition you received
in these or community work. You may attach a separate sheet.)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
IN WHICH ACTIVITIES/ATHLETICS DO YOU WISH TO PARTICIPATE WHILE AT COLLEGE?
BLUEGRASS ENSEMBLE
CHEERLEADING
CHOIR/CHORUS
CONCERT BAND
DANCE TEAM
DRAMA/THEATRE
FRATERNITY OR SORORITY
JAZZ BAND
INTRAMURAL SPORTS
MARCHING BAND
NEWSPAPER
OUTDOOR RECREATION
PEP BAND
RELIGIOUS ACTIVITIES
ROTC
STUDENT GOVERNMENT
Men’s Intercollegiate
BASEBALL
BASKETBALL
CROSS-COUNTRY
FOOTBALL
GOLF
TENNIS
Any studnet who plans to participate in an intercollegiate sport must register with the NCAA Eligibility Center at
http://web1.ncaa.org/ECWR2/NCAA_EMS/NCAA_EMS.html#
Women’s Intercollegiate
BASKETBALL
CROSS-COUNTRY
GOLF
LACROSSE
SOFTBALL
TENNIS
VOLLEYBALL
FAMILY DATA (Applicants 25 years of age and older are not required to complete this section.)
FATHER’S/ GUARDIAN’S NAME OCCUPATION PHONE
_______________________________________________________________________________________________________________________________________
ADDRESS
CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
MOTHER’S/GUARDIAN’S NAME OCCUPATION PHONE
_______________________________________________________________________________________________________________________________________
ADDRESS
CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
SPOUSE’S NAME
OCCUPATION PHONE
_______________________________________________________________________________________________________________________________________
ADDRESS
CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
PLEASE LIST NAMES AND RELATIONSHIP OF ANY RELATIVES WHO HAVE ATTENDED UVA-WISE (FORMERLY CLINCH VALLEY COLLEGE).
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
STATEMENT OF EDUCATIONAL GOALS
To supplement the information supplied by your academic records, you are strongly encouraged to provide a Statement of Educational Goals. Please write
a short essay on a separate sheet and include with your Application for Admission.
LEGAL DISCLOSURE (Required for admission)
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? YES
NO If yes, please enclose
an explanation. If you are charged with a criminal offense after you submit this application, notify the Office of Admissions in writing immediately.
HAVE YOU EVER BEEN SUSPENDED OR EXPELLED FROM ANY HIGH SCHOOL, COLLEGE OR UNIVERSITY? YES
NO
If yes, please enclose an explanation. If you are suspended or expelled after submitting your application, notify the Office of Admissions in writing immediately.
THE HONOR SYSTEM
The Honor System, adopted by the College in 1956, is a form of student self-government under which all students pledge to cooperate in acting honestly
and honorably. Specifically, the System rests on the premise that lying, cheating, and stealing are not tolerable within the College community. The Honor
System is administered by an Honor Court elected by the student body and composed of representatives from each class. It is grounded in the belief that
students are honest and trustworthy. A violation of the System is an offense against the entire student body. A violation can result in dismissal from the
College or imposition of an intermediate sanction. The College will automatically enforce any sanction imposed by the Honor Court on a student certified
to be guilty of a breach of the Honor System.
I hereby apply for admission to The University of Virginia’s College at Wise and certify that the information provided on this application is true to the best of
my knowledge. I understand that omitting information or providing false information will result in denial or dismissal from the College. If accepted, I agree to
comply with and be governed by all rules and regulations of the College. I further agree to subscribe to the Honor System administered by the student body.
DATE
APPLICANT’S
SIGNATURE (Required for admission) _______________________________________________________________________________________________________________________________________
Information provided on this application may be sent to the Virginia State Police and other state and federal agencies as required by law.
In accordance with federal law, the law of the Commonwealth of Virginia, and the policies of the Rector and Visitors of the University of Virginia, the College does not discriminate in
any of its programs, procedures, or practices against any person on the basis of age, citizenship, color, handicap, sex, sexual orientation, or status as a disabled veteran or veteran of
the Vietnam era. The College operates equal opportunity and affirmative action programs for faculty, staff, and students. The Equal Opportunity/Affirmative Action Office (EO/AA)
is responsible for the enforcement of the College’s nondiscrimination obligations. An applicant for admission or employment or any student or employee may file a discrimination
complaint with the EO/AA Officer, the University of Virginia’s College at Wise, 1 College Avenue, Wise, VA 24293.
APPLICATION FOR VIRGINIA’S IN-STATE TUITION PRIVILEGES
Completion of this form is required to claim in-state tuition privileges pursuant to Section 23-7.4 of the Code of Virginia. All
questions must be answered. Section I must be completed by the applicant. Section II must be completed by the parent, legal
guardian, or spouse if the applicant is under the age of 19 or financially dependent. Supporting documentation may be requested.
Failure to submit a complete application could result in being classified as an out of state student for tuition and fee purposes.
SECTION I (To be completed by all applicants.)
APPLICANT’S INFORMATION (Please print.)
_______________________________________________________________________________________________________________________________________
FIRST MIDDLE LAST
SOCIAL SECURITY NUMBER BIRTH DATE (Month/Day/Year) _______________________________________________________________________________________________________________________________________
HOW LONG HAVE YOU LIVED IN VIRGINIA? _______________YEARS_________________MONTHS
CITIZENSHIP STATUS
U.S. CITIZEN
PERMANENT RESIDENT (Please provide copy of both front and back of Form I-551/Green Card.)
NON U. S. CITIZEN VISA TYPE _____________________________________Date of Issuance__________________Date of Expiration____________________
(please include copy of Visa)
WHERE HAVE YOU LIVED FOR THE PAST TWO YEARS? (List current address first – physical address, not P.O. box.)
CURRENT
ADDRESS CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
FROM
(Month/Year) TO (Month/Year)
_______________________________________________________________________________________________________________________________________
PREVIOUS
ADDRESS CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
FROM
(Month/Year) TO (Month/Year)
_______________________________________________________________________________________________________________________________________
WHERE HAVE YOU WORKED FOR THE PAST YEAR?
CURRENT EMPLOYER STREET ADDRESS CITY/STATE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)HRS PER WEEK
_______________________________________________________________________________________________________________________________________
PREVIOUS EMPLOYER STREET ADDRESS CITY/STATE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)HRS PER WEEK
_______________________________________________________________________________________________________________________________________
VETERAN OR ACTIVE DUTY MEMBER OF U.S. ARMED FORCES
PLACE A CHECK MARK BESIDE ANY THAT APPLY TO YOU:
HAVE LEGAL DEPENDENTS OTHER THAN SPOUSE
MARRIED
BOTH PARENTS DECEASED, NO ADOPTIVE LEGAL GUARDIAN
WARD OF THE COURT UNTIL THE AGE OF 18 (COURT DOCUMENTATION REQUIRED)
If you checked any of the items, please complete the remainder of Section I, skip Section II, and sign at the end of the form (reverse).
If you did not check any of these, your parent/guardian should complete Section II and you both must sign at the end of the form (reverse).
DO YOUR PARENTS, SPOUSE, OR LEGAL GUARDIAN PROVIDE MORE THAN HALF OF YOUR FINANCIAL SUPPORT?
DO YOUR PARENTS, SPOUSE, OR LEGAL GUARDIAN CLAIM YOU AS A DEPENDENT FOR TAX PURPOSES?
(If yes to either question above, Section II must be completed by your parents, spouse, or legal guardian.)
YES
YES
IF YOU ARE MARRIED, DO YOU WANT TO CLAIM ELIGIBILITY FOR IN-STATE TUITION ON YOUR SPOUSE’S DOMICILE?
(If yes to the question above, Section II must be completed by your spouse.)
WILL YOU HAVE FILED A TAX RETURN OR PAID INCOME TAXES TO ANY STATE OTHER THAN VIRGINIA?
YES
NO
NO
YES
NO
NO
If yes, which state(s)? ____________________________________________________________________________________________________________________
FOR THE ENTIRE TWELVE MONTHS PRIOR TO THE TERM IN WHICH YOU PLAN TO ENROLL WILL YOU HAVE:
Filed a tax return or paid income taxes to Virginia on all earned income?
Been a registered voter in Virginia?
Held a valid Virginia driver’s license?
YES
YES
YES
NO
NO
NO
If yes, date issued (Month/Year): ___________
Owned or operated a motor vehicle registered in Virginia?
YES
Are you or any member of your family presently on active duty?
NO
YES
NO If yes, check:
Self
Spouse
Will Virginia income taxes have been paid on all military income for the twelve months prior to enrollment?
Is Virginia listed on your Leave and Earnings Statement (LES)?
YES
within Virginia, Washington D.C., or a state contiguous to Virginia?
YES
Parent/Legal Guardian
NO
NO (Attach a copy of your current LES) Are you assigned to a permanent duty station
YES
NO (If yes, provide a copy of military orders)
ANSWER THIS QUESTION ONLY IF YOU LIVE OUTSIDE VIRGINIA BUT WORK IN VIRGINIA:
Will you have lived outside Virginia, worked in Virginia, earned at least the equivalent of a full time wage salary, and paid Virginia income taxes on all taxable
income for at least 12 months prior to enrollment? YES
NO (If yes, please attach a copy of your current Virginia income tax forms.)
SECTION II
(To be completed by the parent, court-appointed legal guardian, or spouse. A signature is required at the end of this section. Please complete
Section II in its entirety, failure to answer all questions may result in the applicant being assessed out-of-state tuition rates.)
PARENT/SPOUSE/LEGAL GUARDIAN INFORMATION (Please print.)
FIRST MIDDLE LAST
_______________________________________________________________________________________________________________________________________
RELATIONSHIP TO APPLICANT
Parent
Spouse
Legal Guardian (court documentation required)
CITIZENSHIP STATUS
U.S. CITIZEN
PERMANENT RESIDENT (Please provide copy of both front and back of Form I-551/Green Card.)
Non U.S. Citizen VISA TYPE ______________________________________Date of Issuance___________________Date of Expiration____________________
(please include copy of Visa)
HOW LONG HAVE YOU LIVED IN VIRGINIA? _______________ YEARS _______________ MONTHS
WHERE HAVE YOU LIVED FOR THE PAST TWO YEARS? (List current address first – physical address, not P.O. box.)
CURRENT ADDRESS CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)
_______________________________________________________________________________________________________________________________________
PREVIOUS ADDRESS CITY/STATE ZIP CODE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)
_______________________________________________________________________________________________________________________________________
WHERE HAVE YOU WORKED FOR AT LEAST ONE YEAR PRIOR?
CURRENT EMPLOYER STREET ADDRESS CITY/STATE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)HRS PER WEEK
_______________________________________________________________________________________________________________________________________
PREVIOUS EMPLOYER STREET ADDRESS CITY/STATE
_______________________________________________________________________________________________________________________________________
FROM (Month/Year) TO (Month/Year)HRS PER WEEK
_______________________________________________________________________________________________________________________________________
FOR THE ENTIRE TWELVE MONTHS PRIOR TO THE TERM IN WHICH THE STUDENT PLANS TO ENROLL, WILL YOU HAVE:
Been employed in Virginia?
YES
NO
Filed a tax return or paid income taxes to Virginia on all earned income?
YES
NO
Been a registered voter in Virginia?
YES
NO
Held a valid Virginia driver’s license?
YES
NO If yes, date issued (Month/Year): ____________________________________
Owned or operated a motor vehicle registered in Virginia?
YES
NO
WILL YOU HAVE CLAIMED THE STUDENT AS A DEPENDENT FOR FEDERAL AND VIRGINIA INCOME TAX PURPOSES PRIOR TO THE TERM IN WHICH
THE STUDENT WILL ENROLL? YES
NO
WILL YOU HAVE PROVIDED MORE THAN HALF OF THE APPLICANT’S FINANCIAL SUPPORT FOR AT LEAST ONE YEAR PRIOR TO THE TERM IN WHICH
THE APPLICANT WILL ENROLL? YES
NO
WILL YOU HAVE FILED A TAX RETURN OR PAID INCOME TAXES TO ANY STATE OTHER THAN VIRGINIA?
YES
NO
IF YES, WHICH STATE(S)? ___________________________________________________________________________________________________________________
ARE YOU PRESENTLY IN THE MILITARY?
YES
NO (If yes, answer A, B, and C below.)
A. Have income taxes been paid to Virginia on all military income for the twelve months prior to the term in which the student will enroll?
YES
NO
B. Is Virginia listed on your Leave and Earnings Statement (LES)?
YES
NO (Please attach a copy of your current LES)
C. Are you assigned to a permanent duty station within Virginia, The District of Columbia, or a state contiguous to Virginia?
YES
NO (If yes, please
attach a copy of military orders.)
ANSWER THIS QUESTION ONLY IF YOU LIVE OUTSIDE VIRGINIA BUT WORK IN VIRGINIA.
Will you have lived outside Virginia, worked in Virginia, earned at least the equivalent of a full-time wage salary, and paid Virginia income taxes on all taxable
income in this Commonwealth for at least twelve months prior to the term in which the student will enroll?
YES
NO (If yes, please attach a copy of your
current Virginia income tax forms.)
I certify that the information I have provided above is true.
SIGNATURE OF APPLICANT DATE
_______________________________________________________________________________________________________________________________________
SIGNATURE
OF PARENT, SPOUSE, OR LEGAL GUARDIAN DATE
_______________________________________________________________________________________________________________________________________
Please review your responses carefully before submitting this form. This information will be used to determine in-state/out-of-state classification.
Incomplete or inaccurate information will delay your course registration.
The University of Virginia’s College at Wise
Office of Admissions, 1 College Avenue, Wise VA 24293
[email protected]
(888) 282-9324 (toll free)
(276) 328-0102 (local)
www.uvawise.edu