APPLICATION FOR
RE-ADMISSION
A. Re-Admission Information (Please Print or Type Clearly)
This information is required in considering the applicant’s request for admission.
Name
Mr.
Ms.
Miss __________________________________________________________________________________
Last First Middle
Social Security Number _______________________________________ Telephone Number ( _______ ) _______________________________
Mailing Address _________________________________________________________________________________________________________
Street and Number
______________________________________________________________________________________________________________________
City State Zip
Marital Status
Married
Single
Separated
Divorced
Widowed
Term Last Attended __________________________________________ Major at that Time ___________________________________________
Term You Plan to Return ______________________________________ Current Major ______________________________________________
Are any of your records under a different name?
Yes
No If so, what name _____________________________________________
Have you attended any other college since your last enrollment at Darton?
Yes
No
If so, give the names of all colleges attended and the dates of attendance.
______________________________________________________________________________________________________________________
Name of College City/State Dates of Attendance Degree
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
If you have attended another college since your last enrollment, are you applying as a
Transfer
Transient
Auditor
Irregular/Non-Degree
Anticipated enrollment pattern
Day Classes Only
Evening Classes Only
Combination of Day &-Evening Classes
Based on the residency definition in the current catalog, what is your residency classification?
Resident of Georgia. County of Residency _________________________________________
Non-resident of Georgia. State of Residency ___________________________________________
Non-resident of Georgia. Military or military dependent. State of Residency ___________________________________________
I understand that falsification of any statement above constitutes fraudulent enrollment and may result in loss of all credits.
Signature _______________________________________________________________ Date __________________________________________
APPLICATION FOR RE-ADMISSION
FOR OFFICE USE ONLY
Information Received
By Phone
By Letter
In Person
Primary Campus
Main
Cordele
On-Line Only
Thomasville
E-mail Address