APPLICATION FOR GENERAL ADMISSION(FOR FACULTY AND STAFF ONLY)

FAYETTEVILLETECHNICALCOMMUNITY COLLEGE

Admissions Office ● PO Box 35236 ● 2201 Hull Road ● Fayetteville, NC28303-0236

DIRECTIONS: Please PRINT your answers using a black ball-point pen. Please answer every question. Incomplete or illegible application cannot be processed! Non-US citizens will be required to provide additional documentation. Completion of this application admits you as a Special Credit student. To be eligible for Financial Aid or VA benefits, you must be program approved; additional steps are required.

NOTE: Use name as it appears on your Social Security Card

Last Name: / Home Telephone / ()
First Name: / Work Telephone / ()
Middle Name: / USED FOR STATISTICAL RECORD KEEPING ONLY
GENDER: MaleFemale
Former Last Name (Maiden):
Address: / Social Sec. No. / / / /
City: / Date of Birth: (MM/DD/YYYY)
State: / Zip: / ETHNICITY
E-Mail: / Are you Hispanic or Latino?YesNo
Hispanic/Latino, Mexican, Puerto Rican, Cuban, Central or South American or other Spanish origin or culture, regardless of race
Which Semester and Year Do You Plan to Attend? / RACE
Fall (Aug-Dec) / Spr. (Jan-May) / Sum (May-Jul) / Year: / Select one or more of the following racial categories / American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
Islander
White
Do You Plan to Enroll:Full-timeORPart-time / Enter Program Code: / (See back for code)
Indicate Your Long Term Goals
Obtain Associate Degree, Diploma, Certificate (GR) / Take Courses to Transfer to Another College (TR)
Enhance My Job Skills In My Present Field of Work (EP) / Take Courses for Personal Interest (PE)
Enhance My Job Skills for a New Line of Work (EN) / Unknown (GU)
Are You a U.S. Citizen? Yes No or U.S. Permanent Resident / Type of Visa:
If not a U.S. citizen, Country of Citizenship / Resident Alien number :
Are you a Resident of North Carolina? Yes No / County of Residence:
To Which State Do You PayState Income Tax? ______ / Driver License Number & State:
Have You Lived in NC Continuously for the Past 12 Months? Yes No / If No, where
Are You Active Duty Military? YesNo / If Yes, What Branch of Service? / Which State Is Your Permanent Duty Station?
If Active Duty or Military Family Member: What Is the Expiration Date on Your Military I.D. Card?
Where is Your Sponsor’s Permanent Duty Station?
Are You a Senior Citizen (65 or Older)? Yes No
FOR OFFICIAL USE ONLY
Residency
In-State (CountyCode: ______)
Out-of-State (State:______)
Staff Initial: ______Date: ______/ Student Type
SENR (Senior)
EMPL (Employee)
MILD (Military Dep.)
MILI (Active Duty Military)

Check & Complete each educational level that describes you:

CurrentHigh School Student / School:Circle Grade Completed: 7 8 9 10 11
High School Graduate / School: / State: / Date of Graduation: (Mo/Yr):
Non-HighSchool Graduate
GED or
AdultHigh School / School: / State: / Date of Graduation: (Mo/Yr):
1 yr College Diploma / Associate Degree / Bachelor’s Degree / Master’s Degree or Higher
Please list ALL colleges and universities previously attended starting with the most recent:
Name of College/University
NOTE: PLEASE DO NOT USE ABBREVIATIONS / Years Attended / State or Country
Start Year / End Year

EMPLOYMENT STATUS:Full TimePart TimeUnemployed

ACADEMIC PROGRAM AREAS

Additional Diploma & Certificate Programs are available, but not listed due to space limitations.Go to FTCC website,

FTCC Form A-19 Revised 09/11/2012

A25100Accounting

A30100Advertising & Graphic Design

A35100A/C, Heating & Refrigeration

A40100Architectural Technology

A10300ANAssociate Degree Nursing

A10100Associate in Arts

A10200Associate in Fine Arts

A10300Associate in Gen. Education

A10400Associate in Science

D60100Auto Body Repair

A60160Automotive Systems Tech.

C55120Basic Law Enforcement Trg.

A20100Biotechnology

A35140Building Construction Tech.

A25120Business Administration

D35180Carpentry

A40140Civil Engineering Technology

A55370Community Spanish Interpreter

A25130Computer Programming

D55140Cosmetology

A55180Criminal Justice Technology

A55200Culinary Technology

A10300DADental Assisting

A10300DHDental Hygiene

A55220Early Childhood Associate

D35220Electrical/Electronics Tech.

A40200Electronics Engineering Tech.

A10300ESEmergency Medical Science

A55240Fire Protection Technology

A55260Funeral Service Education

D55260NC Funeral Director

A25200Healthcare Management Tech.

A1524AHorticulture Tech.Mgmt..

A25240Hotel & Restaurant Mgmt.

A25260Information Systems

A25270Information Systems Security

A25290Internet Technologies

C25290C8Interactive i3D

A50300Machining Technology

A25310Medical Office Administration

A10300NMNuclear Medicine Technology

A25360Office Administration

A25380Paralegal Technology

A10300PHPharmacy Technology

A10300PTPhysical Therapist Assistant

D35300Plumbing

A55340Postal Service Technology

A10300PNPractical Nursing

A10300RARadiography

A10300RCRespiratory Care

A10300SPSpeech-Language Path. Asst.

A10300STSurgical Technology

A40380Surveying Technology

A25290Web Technologies

D50420Welding

T90990Unknown or Unlisted Program

FTCC Form A-19 Revised 09/11/2012