Application For Admission Form Page 2
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1
2Beaufort County Community College
Career and College Promise Program
Year Entering
Full Time
Fall Semester
Application for Admission
Part Time
Spring Semester
Summer Term
-
-
SOCIAL SECURITY NUMBER
LAST NAME (SR. II. ETC.)
FIRST NAME
MIDDLE NAME
OTHER NAMES
-
AREA CODE
HOME NUMBER
MAILING ADDRESS
STATE
ZIP
CITY
COUNTY
E-MAIL_________________________________________________________________________________
CITIZENSHIP INFORMATION (FPER)
RESIDENCY INFORMATION
Select the appropriate designation:
U.S. Citizen
Are you a legal resident of North Carolina?______Yes ______No
Non-Citizen, Country of Citizenship
__________________________________________________
Have you maintained your residence in North Carolina
Permanent Resident Alien
for at least 12 months immediately prior to the date of
Resident Alien Card Number __________________
Issue Date: Month/Day/Year____ /_____/_______
enrollment?
______Yes_______No
Refugee
Non-Immigrant Alien
If no, in what state did you reside prior to moving to
(Check one)
Non-Immigrant Visa Type:
_____________________________________
North Carolina?
B1 B2 F1 H1 J1 Other (OV)
No visa/Undocumented (NV)
I certify that the information above is true and accurate and that my legal residence for tuition purposes is as shown. I also, hereby certify that the information
provided in this application is complete and correct to the best of my knowledge. I further understand that falsification or failure to supply the correct information
may be considered grounds for denial of admission or dismissal after admission.
X__________________________________________________________________
_____________________________________________________________
SIGNATURE
DATE
(month)
(day)
(year)
EDUCATION (XNCA)
Did your father receive a four-year college degree? Yes
No
GRADUATION FROM
H
HIGH SCHOOL
HIGHEST
Did your mother receive a four-year college degree? Yes
No
GRADE
G
GED GRADUATE
COMPLETED
RACE
ETHNICITY
For individuals who are non-Hispanic/Latino:Select one or more of the following racial categories:
Are you Hispanic or Latino?___Yes (HIS)___No (NHS)
Hawaiian/Pacific Islander (HP)
American
Indian/
Alaska Native
(AN)
Hispanic/Latino: Mexican, Puerto Rican, Cuban, Central or
White (WH)
Asian
(AS)
South American or other Spanish origin or culture,
Black or African American (BL)
Other
regardless of race.
SEX
BIRTHDAY
M
F
MONTH
DATE
YEAR
NOTE: Questions concerning age, race and sex provide information necessary to complete various reports required by state and federal agencies.
Responses to these questions are not used as admission criteria. The information provided by the applicant on this form is governed by Public Law
93-380. Specifically, the Family Rights and Privacy Act delineates requirements designed to protect the privacy of students and parents. See College
catalog for details.
In an emergency, notify:____________________________________________Phone: (
)________________________
Schools attended (last high school, GED testing center, college(s):
NOTE: Students are responsible for requesting that their official transcripts (including high school) be sent to:
Admissions Office, BCCC, P.O. Box 1069, Washington, NC 27889, 252-940-6237
NOTE: BE SURE TO COMPLETE THE BACK OF THIS FORM
Your social security number may be provided voluntarily.
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