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.
Please mail or fox your application packet to ONE of the following institutions:
Mr. Oupa Seane, Executive Director
FLAWI
1 UNF Drive
Jacksonville, FL 32224
Fax: (904) 620-1790
Dr. Brenda Simmons, Director
FLAWI
Florida Community College at Jacksonville
4501 Capper Road C-102
Jacksonville, FL 32218
Fax: (904) 713-4853
Mrs. Agnes Coppin
FLAWI
Florida A&M University
302 North Perry Paige Building
Tallahassee, FL 32307
Fax: (850) 561-2587