Form F1 - Application For Admission
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1
2INTERNATIONAL (F1) APPLICATION FOR ADMISSION
HALIFAX COMMUNITY COLLEGE
Admissions Office ● Halifax Community College ● Weldon, NC 27890
Last Name:______________________________________________
(
) ________________________________
Home Telephone
First Name:_______________________________________________
Work/Cell Telephone (
)_________________________________
Middle Name:_____________________________________________
USED FOR STATISTICAL RECORD KEEPING ONLY
□
□
Male
Female
GENDER:
Former Last Name (Maiden):________________________________
Address:_________________________________________________
Date of Birth: (MM/DD/YYYY) _______/_________/__________
City:____________________________________________________
ETHNICITY
□
□ No
State:_________________
Zip: __________________________
Yes
Are you Hispanic or Latino?
Hispanic/Latino, Mexican, Puerto Rican, Cuban, Central or South
E-Mail:___________________________________________________
American or other Spanish origin or culture, regardless of race
RACE
Academic Goal
□
□
Native Hawaiian or Other Pacific Islander
Obtain Associate Degree, Diploma, Certificate (GR)
□ White
□
Take Courses for Personal Interest (PE)
□
American Indian or Alaska Native
□
Unknown (GU)
□
Asian
□
□
Enhance My Job Skills In My Present Field of Work (EP)
Black or African American
□
Enhance My Job Skills for a New Line of Work (EN)
CITIZENSHIP AND IMMIGRATION INFORMATION
Country of Citizenship________________________________ Country of Birth_________________________________________
LOCAL (USA) CONTACT INFORMATION
Name: __________________________ Relationship: _______________ Home/Cell No.: _____________ Work No.: ______________
Address: ________________________________________ City: __________________ State: __________ Zip: __________________
Check & complete each educational level that describes you:
□
High School Graduate
School:
Country/State:
Date of Graduation: (Mo/Yr):
□
□
GED or
Adult High School
School/Institution:
Country/State:
Date of Graduation: (Mo/Yr):
□
□
□
□
Bachelor’s Degree
Master’s Degree or Higher
1 yr College Diploma
Associate Degree
Please list ALL colleges and universities previously attended starting with the most recent:
Name of College/University Attended
NOTE: PLEASE DO NOT USE ABBREVIATIONS
Dates Attended
State or Country
Start Year
End Year
4/2013
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