Statement

Baruch College – Human Resources Nonresident Alien Statement I was a resident of [insert the name of the country under whose treaty you claim exemption or of which you are a resident] on the date of my arrival in the United States. I am not a U.S. citizen. I have not been lawfully accorded the privilege of residing permanently in the United States as an immigrant. I am presently in the United States solely for the purpose of my education or training at [insert the name of the university or other recognized educational institution at which you study]. I arrived in the United States on the United States before beginning study or training]. Please list below every time you entered the United States, the visa status of each entry and the primary purpose of the visits in order for the College to determine your eligibility to remain a Nonresident alien. Dates of other entries into the U.S. and/or dates of changes in Visa Status Visa Type Primary Purpose for visit Dates of Departures [insert the date of your last arrival in Under penalty of perjury, I declare that this statement, to the best of my knowledge and belief, is true, correct, and complete. Name: Signature: Rev. 4/4/03 A. Douglas SS#: Date: