UNIVERSITY OF HAWAI'I System Application Form PIEASE TYPF. OR PRINT CLEARLY IN INK. COMPLETE BOTH SIDES OF THIS FORM, DETACH, AND SUBMIT TO THE CAMPUS ADMISSIONS OFFICE. SEMESTER ENTERING SOCIAL SECURITY NUMBER LEGAL NAME: FAMILY/LAST FIRST/GIVEN FULL MIDDLE ANY OTHER NAMES USED Summer ON TRANSCRIPTS. ETC. Fall Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Spring 1120 · Street Sacramento. CA '958 ~ 4 Sacramento. CA '958 ~ 4 CURRENT MAILING ADDRESS NUMBER STREET CITY OR PROVINCE STATE OR COUNTRY ZIP/POSTAL CODE UNTIL PHONE month/day/year (home) (cell) PERMANENT MAILING ADDRESS NUMBER STREET CITY OR PROVINCE STATE OR COUNTRY ZIP/POSTAL CODE (work) GENDER BlRTHDATE BIRTHPLACE CITIZENSHIP NON-US CITIZEN-VISA TYPE (attach copy of green card, if any) month/day/year LH FEMALE (state or foreign country) DUSA D STUDENT VISA D Permanent Resident-DATE REC DMALE D OTHER _ /_ _/_ _ (specify country) D OTHER (specify) WERE ANY OF YOUR ETHNICITY (check one) RACE [select one or more) See instructions for listing E-MAIL ADDRESS ANCESTORS HAWAIIAN? DHispanic or Latino AA Al CA CH Fl GC HW IN IP D Yes D No Hispanic or Latino KO LA MC OA OP SA TH TO VI NAME OF HIGH SCHOOL GRADUATED/WILL GRADUATE FROM STATE/COUNTRY MONTH/YEAR GRADUATED/WILL GRADUATE LIST EVERY COLLEGE, UNIVERSITY. BUSINESS AND POST-SECONDARY SCHOOL ATTENDED, INCLUDING ANY UH CAMPUS, AND THE ONE YOU ARE CURRENTLY ENROLLED IN. IF ANY NAME OF INSTITUTION ClTY/STATE ATTENDED/ATTENDING NAME OF MONTH/YEAR (Do not use abbreviations) Attach additional sheet if necessary OR FROM THROUGH ph&fax DEGREE. DIPLOMA EXPECTED OR LIST MOST RECENT FIRST CITY/COUNTRY MONTH/YR MONTH/YR OB CERTIFICATE RECEIVED Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Sacramento. CA '958 ~ 4 Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Sacramento. CA '958 ~ 4 /_ Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Sacramento. CA '958 ~ 4 Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Sacramento. CA '958 ~ 4 Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation 1120 · Street Sacramento. CA '958 ~ 4 COMPLETE THIS SECTION IF YOU ARE CURRENTLY ENROLLED IN A COLLEGE OR UNIVERSITY (attach additional sheet if necessary) NAME OF COLLEGE OR UNIVERSITY CURRENTLY ATTENDING LOCATION (CITY/STATE) TERM/YEAR CURRENTLY ENROLLED IN COURSES CURRENTLY ENROLLED IN Mr. To.ks Omishakin. o·-rertor., Catifom:ia Depanmen1 of Transportation COURSE TITLE DEPARTMENT 1120 · Street CREDIT HOURS Sacramento. CA '958 ~ 4 Example: World Civilization I History 3 sem hrs IF YOU HAVE PREVIOUSLY APPLIED FOR ADMISSION TO A UH CAMPUS, INDICATE THE SEMESTER, YEAR, AND DECISION TAKEN. DO YOU PLAN TO ATTEND: DDAYCLASSES DEVENINGCLASSES DBOTH CAMPUS APPLIED TO: _ SEMESTER; YEAR D ACCEPTED D NOT ACCEPTED LIST YOUR CHOICE OF CAMPUSES. MAJORS, AND CERTIFICATES/DEGREES YOU ARE SEEKING CAMPUS MAJOR CERTIFICATE/DEGREE 1. 2.. APPLICANT'S CERTIFICATION I certify that the responses provided on the System Application Form are complete and Irue to the best of my knowledge and belief. I understand that providing incomplete, incorrect, or false information may result in the rescission or denial of my admission and subject me to the requirements and/or disciplinary measures as provided under the University's Student Conduct Cade, I agree to produce certified documents relative to the determination of my residency status upon request and that the provision of incorrect information regarding my residency declaration will also subject me to the requirements and/or disciplinary measures provided for in the University's rules and regulations governing the determination of residency for admission and tuition purposes. Further. I understand that the UH System shares a common database and information pertaining to me may be accessed by all UH campuses. Date: Signature: CONTINUE ON REVERSE SIDE FOR OFFICE USE ONLY ID TUITION STATUS FEE PAYMENT Rec'd #. By. 1 RESIDENCY DECLARATION APPLICANT NAME: _________________________________________ Print Legal Last Name. First Name, Full Middle Name SECTION A I Claim Legal Residency In (check one): Residency Based on (check one): D Hawai'i D My Parent (I am under 18 and not married) D Other State or Country (specify and complete Section E only): D Myself and Parent (I am 18, not yet 19 and not married) D Myself (at least 19 or married) D My Legal Guardian (submit court ordered appointment) SECTION B Check one box that applies: DI am not claimed as a dependent on my parents'/legal guardians' personal State income tax for 2011 □ I am claimed as a dependent on my parents' /legal guardians· personal Hawal'I State income tax for 2011 (parent/legal guardian complete Section C) DI am claimed as a dependent on my parents' /legal guardians' personal State income tax for 2011 for a state other than Hawai'i PARENT/LEGAL GUARDIAN All APPLICANTS SECTION C complete if applicant less than 19 or claimed applicant must complete 1. I claim lesial Residencv in the State of State: Since (mo/vrl: State: Since (mo/vr): 2. I have been oresent in Hawai'i continuously Since (mo/vr): Since (mo/yr): State: D Never Filed State: 0 Never Filed 1. I filed Personal Income Tax in the State of Year from: To: Year from: To: State: D Never Reg'd State: 0 Never Reg'd "· I re11istered to vote in the State of Date (mo/vr): Date (mo/vr): State: D Never Voted State: 0 Never Voted ,. I last voted in the State of Date (mo/vr): Date (mo/vrl: 6. Other (e.S!. emolovment oublic assistance 551) 7. Siltnature and Date □ us D Permanent Resident 8. Parents' /Legal Guardians' Citizenship D Other (soecifv): 9. Relationship to Applicant SECTION D Name your last publicly supported post-secondaryinstitution attended or currently enrolled (include UH campus): lnstitution: __________________ State or Country:. _________ Attended From:.______ To :. ______ Tuition Paid: D Resident D Nonresident D Resident due to nonresident exemption based on: ___________________ SECTION E Indicate if any of the following exemptions from the nonresident tuition differential apply to you: DI do not qualify for any of the exemptions below DI am a full-time faculty or staff member of the University of Hawai'i, or a spouse or legal dependent of such person (Attach employment cantrad) DI am Hawaiian and not a Hawai'i resident (Attach an officialcopy of your Birth Certificate, and if necessary, that of your parents/grandparents documenting Hawaiian ancestry) DI am a citizen of ________________ which has no public institution of higher education granting baccalaureate degrees (See page 7) DI am a member or authorized dependent of a member of the U.S. armed forces, on active duty, stationed in Hawai'i, (Complete Verificationof U.S. Armed Forces below) DI am a member of the Hawai'i National Guard or Hawai'i-based Reserves. (Complete Verification of U.S. Armed Forces below) VERIFICATION OF U.S. ARMED FORCES - attach Military Orders Permission is hereby granted to release information to UH Campus: Member's Relationship to Applicant: Applicant's Signature: ___________________ D Self D Spouse Military Member's Signature: ________________ D Parent 0 Other (specify) ________ To be completed by the Member's Commanding Officer: Name, Rank. & Bra nth of Service of membtr of the U.S. Armed Forces on active duty stationed in H.tw.i,·1, or member of the Hawai'i National Guard or H1w,11'1•buedReserves Estimated Date (mm/dd/yyyy): ______________________________________ Rotation from Hawai•i or separation from mHitary service,whichever 1s earlier (Do Not Use ""Indefinite"' Or Leave Blank) Signature: of Commanding Officer Date Rank and Branch of Service In Hawai'i Pnn\N.ame 2 APPLICATION REQUIREMENTS TOAPPLYONLINE.VISITwww.hawaii.edu/admissions The following are required for application to the University of Hawai'i at Hilo. University of Hawai'i at Manoa. University of Hawai'i-West O'ahu, Hawai'i Commu- nity College, Honolulu Community College, Kapi'olani Community College, Kaua'i Community College, Leeward Community College. Maui College, and Windward Community College, unless otherwise indicated. Applications will not be considered for admission if required documents are not submitted. All documentation is the property of the University of Hawai'i and will not be released. SUBJECT: 2014MlJTCD. CA MUTCD Revision S Substulisil C'onfomumce wilh 2009' iSltona] System Application Form must submit the GED (General Education For UH Hilo post-baccalaureate unclassified Development) test results in addition to your graduate applicants: Certification of degree is re- 2. Application fee, nonrefundable, high school transcript. Your GED results should quired. Official transcripts indicating the degree nontransferable. is required by each campus be sent directly from the testing center to the conferred must be submitted. to which you apply, each lime you apply. A Admissions Office. Homeschooled applicants money order or check payable to "University must check with the Admissions Office of Hawai'i" must accompany the System ADDITIONAL REQUIREMENTS FOR regarding admission policies. Application Form. INTERNATIONAL APPLICANTS OR /,. College, university, business, or post-secondary • Community College applicants: $25 for NON-NATIVE SPEAKERS OF ENGLISH school transcripts are required by UH Hilo, UH nonresident applicants (except for members Please contact the campus admissions office for Manoa. and UH West O'ahu. The Community of the U.S. Armed Forces of the dependents application deadlines. International applicants on Colleges require transcripts only if you wish to of such members, stationed in Hawai'i, on non-immigrant visas are required to submit these transfer those credits. active military duty) additional items to be considered for admission: You must have official transcripts from EACH • UH Hilo applicants: $30 For all applicants 1.