Attestation of Physical Location

Attestation of Physical Location
Which location are you applying to?
I , _________ attest that I am a student of Utah State University and am applying into the following Health Professions Program: _________
Name

First NameLast Name
Health Profession Program that you are applying to
This form provides the program with my physical address at which I am presently dwelling. My current address is as follows.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that should my address change while I am enrolled in the USU Health Professions Program,

Iam to notify the academic advisor immediately upon change of address. I understand that moving out of the USU service area could adversely affect my program completion.
Signature

Clear
Date

MonthDayYear
Date
*Please provide the University the following: Copy of Driver's License or other government-issued ID

Cancelof
Should be Empty: