*Denotes Required information.
*1. Name: ____________________________________________________________________________________
Prefix First Full Middle Last Suffix
2. Former name:____________________________________________________________________________________
*3. Da
te of birth: _________ / ________ / ________
(Month) (Day) (Year)
4. Which college/campus do you plan to attend? Southwest Virginia Community College Main Campus
5. In what type of class will you be enrolling? _______
Credit classes _____ Non-credit/CEU classes
6. What term do you plan to begin classes? 20___ Term: ___ Fall (A
ug-Dec) __ Spring (Jan-May) ___Summer (May-Aug)
7. Have you previously attended, applied for admission to, or been employed by any Virginia Community College?
____
No _____ Yes If yes, SIS ID (Empl ID), if known: _________________________
*8. P
rimary Phone (include area code): (_______) _________ - _____________
*9. M
ailing address: ____________________________________________________________________________________________________
(Street) (City) (State) (ZIP) (Country, if not USA)
*10. Current Residence (Jurisdiction): ________________________________Provide what you consider to be your location of residence. If you
temporarily relocated to your current address to get an education, you should provide your previous location.
11. Have you lived in Virginia for the last twelve mo
nths? ___Yes ___No-Where else did you live? ________ (US state or Foreign
country).
*1
2. Email address: ___________________________________
This address will be your unofficial e-mail address; you will be assigned an
official VCCS e-mail address after enrolling in a qualifying class.
13. Emergency Contact Information:___________________________________________________________________________________________
First Name Last Name Relationship Phone Number Extension
14. Employer (if employed): Business phone: ext. _______
*1
5. Completed high school: Yes No Completed GED: Yes No
16. Ethnicity: _______
None Specified _____ Hispanic/Latino _____ Not Hispanic/Latino
Providing the information below is voluntary. This question complies with the U.S. Department of Education’s new standards for ethnic and racial data collection.
17. Social Security Number: __________ - ___________ - ___________
See privacy statement, which can be obtained in the Admissions Office.
18. Race: _____ None Specified ___ White ___ Black/African American ___ Asian ___ American Indian/Alaska Native
_____Native Hawaiian/Other Pacific Islander
Providing the information below is voluntary. This question complies with the U.S. Department of Education’s new standards for ethnic and racial data collection.
19. Gender: ____ Female ____ Male ___ Not Indicated
20. U.S. Citizen Status: __Native __ Naturalized __ Alien Permanent __ Alien Temporary __Not reported or Not living in the U.S.
________
Not Indicated
Note: If you have been a U.S. Citizen since birth, choose Native. If you became a U.S. Citizen after birth, choose Naturalized. If you are not a U.S. Citizen, choose one of the
types of alien statuses based on your visa. “Alien Permanent”, “Alien Temporary” or “Not reported or Not living in the US” applicants must complete the remainder of the question
on Citizen Status.
Country of Citizenship? ___________ Permanent Status: _______Resident Alien _________Refugee A#:__________
Visa Ty
pe: ____________________ Visa Expiration Date: _________________________ If you chose “Not reported or Not living in the US,” what
Visa Status are you requesting? ________________
21. Primary Language: _____
English _____ Other
22. Military
status: ________ None Specified ___ I have never served in the U.S. Military ___ My spouse has served in the U.S.
Military ___ I
am the dependent of someone who hasDependent ___Active duty ___Active reserves ___ Inactive reserves ___
Retired ___Veteran/VA Ineligible ___Veteran
Branch:____________________________ Date of Entry __________________________
mm/yyyy
