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? YesNo

Whatisyourrace?(Selectanythatapply):

WhiteBlack/AfricanAmericanAsianAmericanIndian/AlaskaNativeNativeHawaiian/OtherPacificIslander

18. Gender:FemaleMaleNotindicated

19. U.S.CitizenshipStatus:

Native

Naturalized

AlienPermanent A#:

PermanentStatus: ResidentAlienAsyleeRefugee

CountryofCitizenship?

AlienTemporary VisaType: VisaExpirationDate:

CountryofCitizenship?

NotindicatedorNotlivingintheU.SDoyouplantoapplyforanF1orM1visa?

20. PrimaryLanguage:EnglishOther

21. U.S.Militarystatus:NoMilitaryServiceSpouseDependentActiveduty Activereserves

InactivereservesNationalGuardRetiredVeteran/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) / DegreesEarned

24.Wereyoususpendedordismissedfromthelastcollegeattended?YesNo

25.FamilyEducationalBackground:

Father’sHighestEducation:

DoNotKnowLessthanHighSchoolAttendedHighSchoolGraduatedfromHighSchool

AttendedCollegeAssociate’sDegreeReceivedaBachelor’sDegreeReceivedapost-Bachelor’sDegree

Mother’sHighestEducation:

DoNotKnowLessthanHighSchoolAttendedHighSchoolGraduatedfromHighSchool

 AttendedCollegeAssociate’sDegreeReceivedaBachelor’sDegreeReceivedapost-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: DualEnrollmentPrincipalPermissionDualEnrollment/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’sInformation
1. 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? YesNo
If“Yes,”isVirginialistedastheTaxStateonyourLeaveandEarning
Statement? Yes No
DateofEntry:
mm/dd/yyyy
OfficialDutyStation:
State
ReportingDate: DurationofOrders:
mm/dd/yyyymm/dd/yyyy / 3.IstheabovepersononactivedutyintheU.S.ArmedForces?YesNoIf“Yes,”isVirginialistedastheTaxStateonhis/herLeaveandEarningStatement? YesNo
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? YesNo
WereyoudischargedfromtheU.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState / 5.IstheabovepersonretiredfromtheU.S.ArmedForces? YesNo
IstheabovepersondischargedfromtheU.S.ArmedForces?YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState
6.AreyouthedependentofsomeoneretiredfromtheU.S.ArmedForces?
YesNo
Areyouthedependentofsomeonedischargedfromthe
U.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState / 6.IstheabovepersonadependentofsomeoneretiredfromtheU.S.
ArmedForces? YesNo
IstheabovepersonadependentofsomeonedischargedfromtheU.S.ArmedForces? YesNo
If“Yes,”dateofdischarge/retirement?
mm/dd/yyyy
TaxStateonLESpriortodischarge/retirement:
TaxState
7.HaveyoulivedinVirginiaforthelast12months? YesNo
If“No,”listaddress(es)forthelast24months
FromDate ToDate
Address
CityStateCountry
FromDate ToDate
Address
CityStateCountry / 7.HastheabovepersonlivedinVirginiaforthelast12months?YesNo
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