Application for Out-of-State Tuition Exemption

Florida/West Africa Linkage Institute

Circle one: Mr. Ms. Mrs.

First Name : _______________________________ Middle Intial : ___________

Last Name : ________________________________

Social Security Number : _______________________________

Birthdate (Month Day Year) : ___________________

Mailing Address : ____________________________________________

City : _____________________ State (or Country) : __________________ ZipCode: _____________________

Email Address:_______________________________________________________

Phone : ______________________________

Current Grade Pt. Average : _____________

Citizenship : __________________________

Passport Number : __________________________ Visa Type : ___________________________________

Are you currently enrolled in a Public Institution in Florida? Circle one - Yes or No

If yes, which one? __________________________________ City : __________________________

If planning to transfer, where? ___________________________________

Academic Term/Year of Exemption: Circle one - Fall or Spring or Summer    Year : ________________

Enrollment in a : Circle one - credit program or non-credit

Major: _____________________________

Anticipated enrollment (*number of semester credit-hours)
(*Note: full time undergraduate = 12 hours/graduate = 9)

I AM or AM NOT currently receiving other scholarship aid : Circle one

If yes, please specify source and amount:

Source : ________________________________________ Amount : _______________________

I certify that the information given in this application is complete and accurate.



Signature : ___________________________________ Date : _____________________________

Out-of-state Tuition Waiver Checklist:

Be sure to include the following items in your application packet.

1. A working email address. (Email will be our primary means of communication with you.)
2. Transcripts from all prior higher education institutions that you have attended.
3. Proof of acceptance or enrollment at a public Florida university or community college. (If you are a new student, a letter from the Director of Admissions will provide proof of acceptance. If you are currently enrolled, proof of registration will be needed.)
4. The completed application form.

Mail or fax your application packet according to the following criteria.

If you are or will be attending a COMMUNITY COLLEGE, send your packet to

Dr. Brenda Simmons, Director
FLAWI
Florida Community College at Jacksonville
4501 Capper Road C-102
Jacksonville, FL 32218
Fax: (904) 766-6654

If you are or will be attending a UNIVERSITY, send your packet to ONE of the following FLAWI offices.

Mr. Oupa Seane, Executive Director
FLAWI
4567 St. Johns Bluff Road, South
Jacksonville, FL 32224
Fax: (904) 620-1790

OR

Mrs. Agnes Coppin
FLAWI
Florida A&M University
302 North Perry Paige Building
Tallahassee, FL 32307
Fax: (850) 561-2587