WISE? ARE YOU UVA
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
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