Application For Admission Form
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Virginia Community College System
NVCC 125-30
Empl.ID _______________________
Rev. 05/03
Application for Admission
IS
OS
_____________________
Northern Virginia Community College
VIRGINIA
Initials _________________________
COMMUNITY COLLEGE
SYSTEM
Date __________________________
1.
A. Have you ever applied to any Virginia Community College? _____ Yes ____ No
If yes, most recent year: _______________________
B. Have you ever been employed by a VCCS college? _____ Yes ____ No
If yes and you know your EMPL. ID, please provide: ___________________________
2. Name:
Last Name
First Name
Full Middle
3. Prefix: ________Mr.
________Miss ________Ms.
________Mrs.
Other: __________________________________________
4. Suffix: ________Jr.
________Sr.
________II
________III
Other: __________________________________________
5. Social Security Number:
or Individual Taxpayer Identification Number: ________________________
(Social security number is not required.)
6. Gender:
Male
Female
7 .
Are you a U.S. citizen?
Yes
No
(If yes, continue to question #8)
If no, what is your Country of Citizenship? ____________________________ Must provide documentation to the College.
What is your current immigration status with the U.S.?
( )
Not in U.S. – I am requesting _______________visa status.
( )
Currently in U.S.
Permanent Status: ( ) Resident Alien
( ) Asylee
( ) Refugee
A# : ___________________
Temporary Status: Specify visa type:______________
and Expiration Date: ___________________________________
Are you requesting a change of status to an F-1 or M-1 visa? ( ) yes ( ) no
8. Is English your native language? Yes
No
9. Date of birth:
Month
Day
Year
10. Racial / Ethnic Group:
American Indian or Alaskan Native
Asian or Pacific Islander
Black
Hispanic
White
Other: __________________________________
1 1. Military Information:
( ) Active Duty
( ) Active Reserves
( ) Inactive Reserves
( ) Retired
( ) Veteran
( ) Military Spouse
( ) Military Dependent Child
Branch: _____________________________________
12. Email address: _________________________________________________________________________________________________
13. Former Name:
Last Name
First Name
Full Middle
14. Home Phone:
Area Code
15. If you live in Virginia, provide your City or County of Residence: _________________________________________________________
If you live outside of Virginia, provide the State and/or Country of Residence: ______________________________________________
16. Mailing Address:
Number / Street / Apt# / City
State / Zip Code /
(Country, if not USA):
State / Zip Code
SIP / Country
17 . If employed: Business Phone:
Area Code
Extension
18. Employer Name: ________________________________________________________________________________________________
19. I wish to begin classes in Year: 20_____
Term: Fall_____
Spring_____
Summer_____
20. I intend to pursue:
______ Credit Classes
_______ Non-Credit Classes
_______ Both
Please complete the rest of this form if you plan to pursue a credit program of study or credit classes.
If you selected “non-credit”, please sign and date the application. If you wish to be considered for in-state
tuition rates, certain contract rates, or are planning to apply for Senior Citizen benefits, you must also complete
the Application for In-State Tuition.
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