Gender:  Single Female Married Female Single Male Married Male  Banner ID: 
Full Legal Name: 
Present Address:   (City,State,Zip)
Permanent Address:  (City,State,Zip)
When did you move to your present address? (include month,day,year)   
Date of Birth:    Phone Number: 
Voter Registration Number:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Michigan Mississippi Missouri Montana Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Automobile License Number:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Michigan Mississippi Missouri Montana Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Driver's License Number:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Michigan Mississippi Missouri Montana Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

2. HOUSING INFORMATION

Do you own the dwelling in which you live?  Yes No
Date of purchase (include month & year): 
Do you own the land on which the dwelling is located?  Yes No
If you do not own your dwelling, do you rent?  Yes No

3. STUDENT INFORMATION

Have you lived in Tennessee continuously since birth?  Yes No
If no, when did your latest stay in Tennessee begin? (include month & year)

Where and when did you complete your high school education? (include school, city,state,month,year) 

Have you ever been a student at The University of Memphis?  Yes No

If YES, when did you enroll?
Semester   Year  UG  Grad  Law 

If NO, when do you plan to enroll?
Semester   Year  UG  Grad  Law 

List the colleges or universities attended other than The University of Memphis.

4. VETERAN INFORMATION

If you have been in active military service, from which state did you enter the service?  Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Michigan Mississippi Missouri Montana Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Which state did you declare to be your home of record? Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Michigan Mississippi Missouri Montana Nebraska Nevada New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Date of entry:    Date of release: 

(If you have not previously done so, please submit a copy of your DD Form 214 discharge with this form).

5. EMPLOYMENT INFORMATION

Please indicate any full-time employment during the last three years and give names of employers, the locations, and dates of employment. (Graduate teaching and research assistantships are not considered as full-time positions).

EMPLOYMENT WITHIN THE PAST TWELVE (12) MONTHS MUST BE VERIFIED BY A LETTER FROM THE EMPLOYER STATING THE DATE EMPLOYMENT BEGAN.

6. PARENTAL INFORMATION (Father)

Father's Full Legal Name: 
His permanent address: 
Father's Occupation: 
Place of Employment: 
Did your father claim you as a dependent on his most recent
income tax return? Yes No
If your father is now living in Tennessee, how long has he been living here?  
If your father has moved from Tennessee, give date of leaving 

If the reason for his being temporarily out of state is due to military service, please secure a COPY of his service record indicating his permanent address and enclose with this form.

7. PARENTAL INFORMATION (Mother)

Mother's Full Name: 
Her permanent address: 
If your mother is now living in Tennessee, how long has she been living here? 
If your mother has moved from Tennessee, give date of leaving 
If remarried, what is her present name? 
Did your mother claim you as a dependent on her most recent income tax return? Yes No

8. GUARDIAN INFORMATION

Do you have a legally appointed guardian?  Yes  No

If YES, please give name and address of guardian and ATTACH A COPY OF THE GUARDIANSHIP PAPERS. A guardian's notarized statement of support should be attached to this form also.

Guardian's Full Legal Name: 
Guardian's Address: 

9. MARITAL INFORMATION

Date of Marriage:   Place of Marriage: 
Spouses's Full Legal Name: 
Has your spouse been enrolled at a college in Tennessee?  Yes  No

If YES, when was he/she enrolled? 

If your spouse currently enrolled at The University of Memphis?  Yes No
How long has he/she been continuously living in Tennessee? 
His/her employer in Tennessee? 
Location: 

10. EXPLANATION OF RESIDENCY REQUEST

What is the basis for your claim to be a resident for fee paying purposes while attending The University of Memphis? You should provide (on a separate piece of paper) detailed information on previous history in Tennessee, family connections and special circumstances that may exist.

I am requesting a change of status for the:

FALL  SPRING  SUMMER 

ALL APPLICANTS MUST READ THE FOLLOWING STATEMENT AND SIGN IN THE APPROPRIATE SPACE BEFORE A RESIDENCY CHANGE CAN BE INITIATED

My signature below is to certify to the correctness and completeness of the information supplied. It further indicates that I understand that the University may contact any of the persons referred to above for the purpose of obtaining additional pertinent information; and that I further understand that any false information provided in the foregoing statements will disqualify me from being considered a resident of Tennessee, and I may be required to withdraw from the University.

Signature of Applicant:   Date: