URG/RGCC Commuter Exemption Form

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Commuter Exemption Form OFFICE USE ONLY

Date:____________________ Dean of Students:_____________________________________ Approved

Denied

STUDENT NAME: First____________________________________Middle_______________________ Last____________________________ I, _____________________________________, am requesting exemption from the Residential Living Requirement for the following reasons: Married Student – Please provide Spouse’s Name and Documentation (I.e. Marriage License): __________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Single Parent With Custody Of Child – Please provide Child’s Name and Proof Of Custody: ____________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Establish Permanent Residency Within 50 Miles Of Campus – Please provide Proof of Home Ownership (I.e. Utility Bill, Deed, Etc.) :_____________________________________________________________________________ __________________________________________________________________________________________________ Extenuating Circumstances – Describe below:_________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Student Signature:_________________________________________Id #: _______________________________________ Parent/Guardian (If Student Under 18 Years Old): __________________________________________________________ Student Email:____________________________________________Student Cell #:_______________________________

Office of Student Affairs • 740.245.7350

Commuter Exemption Form • 8-6-2019JA


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