Form Reg 26 – Fill Out and Use This PDF

NAME __________________________________________________________________________ STUDENT ID NUMBER ________________________________ TERM __________

	RE-ENTRY APPLICATION – NO FEE	BC EMPLOYEE
	Former students who have not attended the college for two or more major terms	________________________
		DATE	TERM
	(excluding Summer) are required to complete all sections of this application
	PLEASE TYPE OR PRINT ALL INFORMATION REQUESTED ON THIS FORM

SOCIAL SECURITY NO. or TAX I.D. NO. ___________________________________________ ❑ Male      ❑ Female      DATE OF BIRTh ________

If a student has a Social Security Number (SSN) or a Taxpayer Identification Number (TIN), federal law requires that it is furnished to Broward College so that it may be included on all documents filed by the institution with the Internal Revenue Service. Students who fail to furnish Broward College with the correct SSN or TIN may be subject to an IRS penalty of $50 unless the failure is due to reasonable cause and not to willful neglect. Students are assigned a college identification number to assist in protecting their identities, as provided by Florida Statute 119.071(5).

LEGAL NAME (last, first, MI/former) ______________________________________________________________________________________________

ADDRESS (street, city, state, zip) ________________________________________________________________________________________________

PhONE (home) ___________________ (work) __________________ (cell)___________________ I am a veteran ❑ Yes	❑ No
COUNTRY OF CITIZENShIP _______________________________________________________ Alien Registration No. A	____________________

ACADEMIC STATUS

❑ I PREVIOUSLY ATTENDED Broward College for ❑ Credit ❑ Audit ❑ Non-Credit ❑ Dual Enrollment ❑ Early Admission

❑I hAVE NOT attended other colleges, universities or technical schools since last enrolled at Broward College.

❑COLLEGE/UNIVERSITY ATTENDED SINCE Broward College. (Official complete transcripts from the colleges/universities must be received at Broward College.

Students whose transcripts are not on file at the college will be blocked from registering for subsequent terms.)

________________________________________________________________________________________________________________________________________________________________

COLLEGES, UNIVERSITIES, etc. (attach separate sheet if needed.)STATECOUNTRYATTENDANCE DATESDEGREES OR CREDITS EARNED

________________________________________________________________________________________________________________________________________________________________

COLLEGES, UNIVERSITIES, etc. (attach separate sheet if needed.)	STATE	COUNTRY	ATTENDANCE DATES	DEGREES OR CREDITS EARNED
STATUS AT LAST COLLEGE ATTENDED: ❑ Eligible to return	❑ Probation, but eligible to return		❑ Suspension/dismissal until (month/year) ____________________

ACADEMIC PROGRAM

I WILL ATTEND BEGINNING:	❑ Fall Term 1 Year_________		❑ Winter Term 2 Year_________	❑ Summer Term 3 Year_________
	❑ Session 1: August-December		❑ Session 1: January-May	❑ Session 1: May-August
	❑ Session 2: August-October		❑ Session 2: January-March	❑ Session 2: May-June
	❑ Session 3: September-December		❑ Session 3: February-May	❑ Session 3: June-August
	❑ Session 4: October-December		❑ Session 4: March-May
CAMPUS PREFERRED: ❑ Central Campus	❑ North Campus	❑ Central Campus ❑ South Campus ❑ Willis Holcombe Center ❑ Pines Center
	❑ Weston Center	❑ Miramar Automotive/Marine Center ❑ Miramar Town Center

DEGREE OR CERTIFICATE AND PROGRAM SELECTION (check one):

❑	Bachelor of Science (B.S.)	❑ Associate in Arts (A.A.)	❑ Associate in Science	(A.S.)
❑	Applied Technology Diploma (A.T.D.)	❑ College Certificate	❑ Non-Degree	❑ Transient (one term)

❑I intend to complete the following credit Program _____________________ (programs are accessible online at www.broward.edu)

❑I am interested in specific credit courses only and do not intend at this time to complete an Associate Degree or Certificate.

❑ My objective at the college is to: ❑ Upgrade Skills

❑ Personal Interest

❑ Transfer

FLORIDA RESIDENT STATEMENT

Please Read This Statement Carefully Before Signing Residency Certification

For the purpose of assessing tuition, a student shall be classified as a “resident” or “non-resident” student based upon Florida Statute S240.1201. Pertinent sections of the law appear below. Please contact a Campus Registration Office if you have questions regarding your residency status. A complete copy of the State Statute, which is the authority for student residency determinations at Broward College, is available online at www.broward.edu. In all applications for admission a Florida applicant, or, if a minor, the parent or legal guardian of the minor applicant, shall make and file with such application a written statement that the applicant is a bona-fide resident for tuition purposes. The burden of establishing facts which justify classification of a student as a “Florida resident for tuition purposes” is on the student. Persons in non-Florida resident status may at- tend Broward College, and they do not need to submit a Florida resident statement.

A FLORIDA RESIDENT for tuition purposes is a person (or if a minor, the parent or legal guardian) who has established legal residence in Florida and has maintained legal residence for at least 12 consecutive months immediately prior to the first day of the re-entry term. Residence during the 12-month qualifying period mus be for the purpose of maintaining a bona-fide domicile rather than maintaining a temporary resi- dence incident to enrollment in an institution of higher education. Students who are non-resident aliens or who are in the United States on a non-immigrant visa will not be entitled to Florida resident status for tuition pur- poses. In determining Florida resident status, the college may require evidence related to legal residence and its duration.

A LEGAL GUARDIAN is a court-appointed guardian or legal custodian of the minor applicant (a person under 18 years of age, not an independent minor by reason of marriage or by court of competent jurisdiction). Legal guardians usually will not be appointed by the Court when the parents of the minor are living and competent, or if the purpose of such appointment would appear to be circumvention of payment of non-resident fees.

SPECIAL CATEGORIES The following persons shall be treated as Florida residents for tuition purposes: active-duty members of the armed services of the United States stationed in this State, their spouses, and de- pendent children; full-time instructional and administrative personnel employed by Florida state public schools, community colleges, and institutions of higher education, and their spouses, and dependent children.

❑I certify that I have been a bona fide Florida resident and have lived in Florida at least 12 months consecutively since _______________________ and I declare under penalty of perjury punishable by law as a misdemeanor under Section 837.06, Florida Statutes, that the foregoing is true and correct. (Two proofs supporting the 12-month requisite are required.)

Drivers License (No., state,date issued) ___________________________________________________ Signature ________________________________________________

Car Registration (No., state, date issued)_______________________________ Voter’s Registration (No., state, date issued) ___________________________________________

OR

❑I have not lived in Florida for at least 12 consecutive months immediately preceding the first day of re-entry and therefore, I will be responsible for payment of tuition and all

applicable non-resident fees. Please indicate in which state you were a legal resident __________ Signature _________________________________________________

GOOD CONDUCT/CITIZEN CERTIFICATION:    Have you ever been incarcerated, convicted of a felony, or experienced disciplinary problems at another educational in- stitution? ❑ Yes ❑ No. If yes, please submit a written statement explaining the circumstances to the Dean of Student Affairs on your preferred campus, for review prior to admission to Broward College. This information will be handled confidentially.

I certify all statements given in this application are accurate to the best of my knowledge. I agree to abide by the rules and regulations of Broward College. I understand the college is authorized to obtain Florida public school records and test scores electronically, if available.

Student’s signature ________________________________________________________________ Date	________________________________
AN EQUAL ACCESS/EQUAL OPPORTUNITY INSTITUTION	REG-26 (Rev. 5/13)
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