APPLICATIONFORADMISSION
FOROFFICEUSEONLY
EmplID IS OS StaffInitial Date
Notice:Inaccordancewith§23.2.2:1oftheCodeofVirginia,yourname,dateofbirth,gender,andstudentidentificationnumberwillbesubmittedtothe
VirginiaStatePolice.Byproceedingwiththeapplicationprocess,youconsenttothissubmission.
Pleasenote:Itwillbenecessaryforapplicantswhowishtobeconsideredforveterans’benefits,financialaid,andHopeScholarship/LifetimeLearningtaxcredittoprovideaSocialSecuritynumbertothecollege.Toprotectyourprivacy,yourSocialSecuritynumberwillnotbeusedasyourstudentidentificationnumber.TheVCCSwillonlyuseyourSocialSecuritynumberinaccordancewithfederalandstatereportingrequirements,andforidentificationpurposeswithintheVCCS.ItshallnotpermitfurtherdisclosureunlessrequiredorauthorizedbytheFamilyEducationalRightsandPrivacyActof1974,20U.S.C.Code1232g,orpursuanttoyourobtainedconsent.
Possessing,brandishing,orusingaweaponwhileonanycollegeorVCCSofficeproperty,withinanycollegeorVCCSofficefacilities,orwhileattendinganycollegeorVCCSeducationalorathleticactivitiesbystudentsisprohibited,exceptwherepossessionisaresultofparticipationinanorganizedandscheduledinstructionalexerciseforacourse,whensecuredinsideavehicle,orwherethestudentisalawenforcementprofessional.Byproceedingwiththeapplicationprocess,youacknowledgeandagreetoabidebythispolicyifacceptedtoaVCCScollege.
PersonalInformation:
1.Name:
PrefixFirstMiddle(Full)LastSuffix
2.SocialSecurityNumber: - - (Note:ProvidingthisdatawillenableyoutousetheVCCSusernamelookupfeatureandresetapasswordforyourusername.)
3.Formername(ifapplicable):
FirstMiddle(Full)Last
4. Dateofbirth: Month Day Year
5.Whichcampusdoyouplantoattend?ChristannaDaniel
6.Inwhattypeofclass(es)willyoubeenrolling? Creditclass(es)Non-creditclass(es)
7.Whattermdoyouplantobeginclasses? 20
Term:Fall(Aug-Dec)Spring(Jan-May)Summer(May-Aug)
8.Haveyoupreviouslyattended,appliedforadmissionto,orbeenemployedbyanyVirginiacommunitycollege?
No Yes-EnterStudentID(EmplID)numberifknown:
9.PrimaryPhoneNumber(includeareacode):( ) -
10. Mailingaddress:
POBox/StreetCityStateZIP/PostalCountry,ifnotUSA
11. City/County/ornon-VAStateofResidence: (Providewhatyouconsidertobeyourlocationofresidence.Ifyoutemporarilyrelocatedtoyourcurrentaddresstoget
aneducation,youshouldprovideyourpreviouslocation.)
12. HaveyoulivedinVirginiaforthelasttwelvemonths? Yes No-Wheredidyoulive?
USstateorForeigncountry
13. Email address: (Thisaddresswillbeyourunofficiale-mailaddress;youwillbeassignedanofficialVCCSe-mailaddressuponsuccessfulprocessingofthisapplication.)
14. EmergencyContactInformation:
FirstNameLastNameRelationshipPhoneNumber
15. Student’sEmployer(ifemployed):
16. Businessphone: ( ) - ext.:
17. Ethnicity:AreyouHispanicorLatino? YesNo
Whatisyourrace?(Selectanythatapply):
WhiteBlack/AfricanAmericanAsianAmericanIndian/AlaskaNativeNativeHawaiian/OtherPacificIslander
18. Gender:FemaleMaleNotindicated
19. U.S.CitizenshipStatus:
Native
Naturalized
AlienPermanent A#:
PermanentStatus: ResidentAlienAsyleeRefugee
CountryofCitizenship?
AlienTemporary VisaType: VisaExpirationDate:
CountryofCitizenship?
NotindicatedorNotlivingintheU.SDoyouplantoapplyforanF1orM1visa?
20. PrimaryLanguage:EnglishOther
21. U.S.Militarystatus:NoMilitaryServiceSpouseDependentActiveduty Activereserves
InactivereservesNationalGuardRetiredVeteran/VAIneligible Veteran
Branch:DateofEntry
mm/dd/yy
(ThisdatatobeusedforSOCreportingpurposes.)
PayGrade MOS/Rating CurrentMilitaryInstallation
Pleasecompletetherestofthisformifyouplantopursueacreditprogramofstudyorcreditclasses.Ifyouselected
“non-creditclasses”forquestion#6above,pleasesignanddatetheapplication.
Educational History:
22.HighSchoolInformation
HighSchool(graduatedorcurrentlyenrolled)
HighSchool
Address
CityStateCountry(ifnotUSA)
ActualorAnticipatedGraduationDate
mm/yy
DiplomaType:Standard ModifiedStandard GeneralAchievement AdvancedStudies Other
(Otherincludes:SpecialDiploma,CertificateofCompletion,orDon’tKnow)
(IfyougraduatedfromVApriorto2003orinastateotherthanVA,selectStandard.)
HomeSchool(graduatedorcurrentlyenrolled)
Address ActualorAnticipatedGraduationDate
StateCountry(ifnotUSA)mm/yy
GED
State
AwardDate
mm/yy
NoHighSchooldiplomaorGED
LastDateAttended: Highestgradecompleted:
mm/yy
23.Colleges/Universitiesinformation.Ifyouhavetakenanycollegeclasses,pleaselistthemostrecentfirst.
IndicateanydegreesearnedinthelastcolumnwithanAforAssociate,BforBachelor’s,MforMaster’s,DforDoctorate,orPforProfessionalDegree.Ifyouhavenotearnedadegree,leavetheDegreescolumnblank.
CollegeorUniversity / City,State/Country(ifnotUSA) / DatesAttended(mm/yy–mm/yy) / DegreesEarned24.Wereyoususpendedordismissedfromthelastcollegeattended?YesNo
25.FamilyEducationalBackground:
Father’sHighestEducation:
DoNotKnowLessthanHighSchoolAttendedHighSchoolGraduatedfromHighSchool
AttendedCollegeAssociate’sDegreeReceivedaBachelor’sDegreeReceivedapost-Bachelor’sDegree
Mother’sHighestEducation:
DoNotKnowLessthanHighSchoolAttendedHighSchoolGraduatedfromHighSchool
AttendedCollegeAssociate’sDegreeReceivedaBachelor’sDegreeReceivedapost-Bachelor’sDegree
Educational Goals:
Tobeconsideredforfinancialaid,studentsmustbeinaplanofstudythatleadstoadegree,diploma,orcertificate.(Includespecialization/sub-plan,ifapplicable.)
CollegeTransferEducationCareer/TechnicalEducationAssociateofArts(AA)AssociateofAppliedArts(AAA)AssociateofScience(AS) AssociateofAppliedScience(AAS)AssociateofArtsandSciences(AAS)
26. Iplantopursueadegree,certificate,ordiplomafrommycommunitycollege.
Planofstudy/sub-plan(refertothecollegecatalog).
Idonotplantopursueadegreeatthistime.Reasonfortakingclasses(checkonlyone):
Upgradingcurrentjobskills
Developingskillsfornewjob
Exploringcareeroptions
Pursuingpersonalinterestorgeneralknowledge
Currentlypursuingdegreeatanothercollege(transient/visitor)
Planningtopursueadegreeatanothercollege(non-degree/transfer)
27.HighSchoolApplicants: DualEnrollmentPrincipalPermissionDualEnrollment/PrincipalPermission
Icertifyunderpenaltyofdisciplinaryactionthatalloftheinformationiscompleteandaccurate.Iagreetosupplythecollegewithsupportingdocumentationrelatedtomyapplication,ifIamrequestedtodoso.
Applicant’sSignature: Date:
Parent/LegalGuardian’sSignature: Date:
(Ifunder18yearsofage)
Thisinstitutionpromotesandmaintainseducationalopportunitieswithoutregardtorace,color,sex,ethnicity,religion,gender,age(exceptwhenageisabonafideoccupationalqualification),disability,nationalorigin,orothernon-meritfactors.
DOMICILE DETERMINATIONFORM
Allstudentstakingcreditclassesmustcompletethe
DomicileDeterminationForm.
Markthedomicilecategorythatappliestoyoubelowfromchoices1-6.Chooseonlyonecategory.
Eligibilityforin-statetuitionispursuantto
Section23-7.4,CodeofVirginia.
Pleasecontactthecollegeadmissionsofficeifyouhaveanyquestions.
1.Self:Iamage24orolderandwanttoclaimeligibilitybasedonmyowndomicile.
2.Self:Iamunderage24andwanttoclaimeligibilitybasedonmyowndomicileforthefollowingreason(s):
IamaveteranoractivedutymemberoftheU.S.ArmedForces.
BothofmyparentsaredeceasedandIhavenoadoptiveorlegalguardian.
Ihavelegaldependentsotherthanmyspouse.
Iamfinanciallyself-sufficient.
Iamawardofthecourtorwasawardofthecourtuntilage18.
Ihaveabachelor’sdegreeandIamworkingonagraduatedegree.
Iammarried.
Youmayberequiredtosupply“clearandconvincingevidence”ofyourstatus.
3.Spouse:Iamage24orolderandwanttoclaimeligibilityforin-statetuitionbasedonmyspouse’sdomicile.
4.Spouse:Iamunderage24andIwanttoclaimeligibilityforin-statetuitionbasedonmyspouse’sdomicile.
5.Parent:Iamunderage24andmyparentsprovidemorethanhalfofmyfinancialsupportand/orclaimmeasadependentfortaxpurposes.
6.LegalGuardian:Iamunderage24andmycourt-appointedlegalguardianprovidesmorethanhalfofmyfinancialsupportand/orclaimsmeasadependentfortaxpurposes.
Ifyoumarkedbox1or2,pleasecompleteSectionAbelow.
Ifyoumarkedbox3,4,5,or6,pleasecompleteSectionBbelow.
A.Applicant’s InformationB.Parent,LegalGuardian,orSpouse’sInformation1. Applicant’sName:
FirstMiddle(Full)Last
Dateofbirth:
(mm)(dd)(yy) / 1.Provide thenameofthepersonuponwhomyouarebasingyourdomicile:
FirstMiddle(Full)Last
2.AreyouaU.S.Citizen? Yes No
If“No,”areyouapermanentresident? Yes No
If“Yes,”whatisyour“Anumber”?If“No,”whatisyourimmigrationstatus? / 2.Usingtheaboveperson’sinformation,answerthequestionsbelow.
IstheabovepersonaU.S.citizen? Yes No
If“No,”ishe/sheapermanentresident? Yes No
If“Yes,”whatishis/her“Anumber”? If“No,”whatishis/herimmigrationstatus?
3.AreyouonactivedutyintheU.S.ArmedForces? YesNo
If“Yes,”isVirginialistedastheTaxStateonyourLeaveandEarning
Statement? Yes No
DateofEntry:
mm/dd/yyyy
OfficialDutyStation:
State
ReportingDate: DurationofOrders:
mm/dd/yyyymm/dd/yyyy / 3.IstheabovepersononactivedutyintheU.S.ArmedForces?YesNoIf“Yes,”isVirginialistedastheTaxStateonhis/herLeaveandEarningStatement? YesNo
DateofEntry:
mm/dd/yyyy
OfficialDutyStation:
State
ReportingDate: DurationofOrders:
mm/dd/yyyymm/dd/yyyy
4.Areyouthedependentofanactivedutymemberinthe
U.S.ArmedForces?
Yes No
If“Yes,”isVirginialistedastheTaxStateonyourLeaveandEarning
Statement? Yes No
DateofEntry:
mm/dd/yyyy
OfficialDutyStation:
State
ReportingDate: DurationofOrders:
mm/dd/yyyymm/dd/yyyy / 4.IstheabovepersonmarriedtoanactivedutymemberoftheU.S.
ArmedForces?
Yes No
If“Yes,”isVirginialistedastheTaxStateontheLeaveandEarning
Statement? Yes No
DateofEntry:
mm/dd/yyyy
OfficialDutyStation:
State
ReportingDate: DurationofOrders:
mm/dd/yyyymm/dd/yyyy
A.Applicant’s InformationB. Parent,LegalGuardian,orSpouse’sInformation
5.AreyouretiredfromtheU.S.ArmedForces? YesNo
WereyoudischargedfromtheU.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState / 5.IstheabovepersonretiredfromtheU.S.ArmedForces? YesNo
IstheabovepersondischargedfromtheU.S.ArmedForces?YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState
6.AreyouthedependentofsomeoneretiredfromtheU.S.ArmedForces?
YesNo
Areyouthedependentofsomeonedischargedfromthe
U.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState / 6.IstheabovepersonadependentofsomeoneretiredfromtheU.S.
ArmedForces? YesNo
IstheabovepersonadependentofsomeonedischargedfromtheU.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState
7.HaveyoulivedinVirginiaforthelast12months? YesNo
If“No,”listaddress(es)forthelast24months
FromDate ToDate
Address
CityStateCountry
FromDate ToDate
Address
CityStateCountry / 7.HastheabovepersonlivedinVirginiaforthelast12months?YesNo
If“No,”listaddress(es)forthelast24months
FromDate ToDate
Address
CityStateCountry
FromDate ToDate
Address
CityStateCountry
8.Forthelast12months,whichofthefollowingappliestoyou:
paidVirginiaincometaxesonallearnedincome
filedasaresidentinanotherstate(liststate)
filedasaresidentinVirginiaandasanon-residentinanotherstate
(liststate)
wasaresidentinastatewithoutincometax(liststate)
hadnotaxableincome / 8.Forthelast12months,whichofthefollowingappliestotheaboveperson:
paidVirginiaincometaxesonallearnedincome
filedasaresidentinanotherstate(liststate)
filedasaresidentinVirginiaandasanon-residentinanotherstate
(liststate)
wasaresidentinastatewithoutincometax(liststate)
hadnotaxableincome
9.Forthepasttwelvemonths,haveyoulivedout-of-state,workedinVirginia,andpaidVirginiaincometaxesonatleast$14,500ofearnedincome? Yes No
If“Yes,”liststate / 9.Forthepasttwelvemonths,hastheabovepersonlivedout-of-state,workedinVirginia,andpaidVirginiaincometaxesonatleast$14,500ofearnedincome? Yes No
If“Yes,”liststate
10.Forthepast12months,haveyou:
heldaVirginiaDriver’slicenseorVirginiaDMVID? Yes No
If“No,”hastheapplicantheldaDriver’slicenseorDMVIDtoanyotherstate?Yes(Liststate) No / 10.Forthepast12months,hastheaboveperson:
heldaVirginiaDriver’slicenseorVirginiaDMVID? Yes No
If“No,”hastheapplicantheldaDriver’slicenseorDMVIDtoanyotherstate?Yes(Liststate) No
ownedoroperatedamotorvehicleregisteredinVirginia?Yes No
If“No,”hastheapplicantownedoroperatedamotorvehicleregisteredinanyotherstate?Yes(Liststate) No / ownedoroperatedamotorvehicleregisteredinVirginia?Yes No
If“No,”hastheapplicantownedoroperatedamotorvehicleregisteredinanyotherstate?Yes(Liststate) No
beenregisteredtovoteinVirginia? Yes No
If“No,”hastheapplicantbeenregisteredtovoteinanotherstate?
Yes(Liststate) No / beenregisteredtovoteinVirginia? Yes No
If“No,”hastheapplicantbeenregisteredtovoteinanotherstate?
Yes(Liststate) No
Pleasenote:Ifyouknowinglyprovideerroneousinformationtoevadepaymentofout-of-statetuitionandfees,youwillbechargedout-of-statetuitionandfeesforeachtermattendedandmaybesubjecttodismissal.Randomauditsofthisinformationwillbeperformed.Icertifyunderpenaltyofdisciplinaryactionthatalloftheinformationiscompleteandaccurate.Iagreetosupplythecollegewithsupportingdocumentationrelatedtomyapplication,ifIamrequestedtodoso.
SignatureofApplicantDateSignatureofParent,LegalGuardian(Ifunder24yearsold),orSpouse Date
RVSD6/10/20136