Fillable APPLICATION FOR ADMISSION (Northern Virginia Community College)

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APPLICATION FOR ADMISSION (Northern Virginia Community College)

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APPLICATION FOR ADMISSION
FOR OFFICE USE ONLY
EmplID ____________________________
IS OS _____________________________
Sta Initial _________________________
Date ______________________________
Notice:
In accordance with §23.2.2:1 of the Code of Virginia, your name, date of birth, gender, and student identication number will be submitted to the
Virginia State Police. By proceeding with the application process, you consent to this submission.
Please note: It will be necessary for applicants who wish to be considered for veterans’ benets, nancial aid, and Hope Scholarship/Lifetime Learning
tax credit to provide a Social Security number to the college. To protect your privacy, your Social Security number will not be used as your student
identification number. The VCCS will only use your Social Security number in accordance with federal and state reporting requirements, and for
identication purposes within the VCCS. It shall not permit further disclosure unless required or authorized by the Family Educational Rights and Privacy
Act of 1974, 20 U.S. C. Code 1232g, or pursuant to your obtained consent.
Possessing, brandishing, or using a weapon while on any college or VCCS oce property, within any college or VCCS oce fa cilities, or while attending
any college or VCCS educational or athletic activities by students is prohibited, except where possession is a result of participation in an organized and
scheduled instructional exercise for a course, when secured inside a vehicle, or where the student is a law enforcement professional. By proceeding with
the application process, you acknowledge and agree to abide by this policy if accepted to a VCCS college.
If you have ever been in foster care, please contact the G
reat Expectations program at 804 -819- 4690 after completing this application .
Personal Information:
1.
Name: ________________________________________________________________________________________
Prex
First
Middle (Full)
Last
Sux
2.
Social Security Number: _____________ - ____________ - _____________
(Note: Providing this data will enable you to look up and reset a password for your username.)
Former name (if applicable):
_______________________________________________________________________
First
Middle (Full)
Last
3.
4.
5.
6.
7.
8.
Date of birth: _______________ Month _______________ Day _______________ Year
Which college/campus do you plan to attend? _______________________________ College _
_______________
Campus
In what type of class(es) will you be enrolling? Credit class(es) Non-credit class(es)
What term do you plan to begin classes? 20___ Term: Fall (Aug -Dec) Spring (Jan -May) Summer (May -Aug)
Have you previously attended, applied for admission to, or been employed by any Virginia community college?
No Yes - Enter Student ID (Empl ID) number if known: ______________
___________________________
9.
Primary Phone Number (include area code): ( ________
__
) _________
__
- _____________
__
10. Mailing address: _________________________________________________________________________________
_________
PO Box/Street
City
State
ZIP/Postal
Country, if not USA
11. City/County/or non -VA State of Residence: ____________________________
____________________________
(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.)
RVSD 6/9/2014
1
125-030 Rev 6/14
Thank you for your interest in applying to NOVA. To apply for admission, you need to complete a brief application and provide basic information about
yourself including contact information, education history and details about your residency.
12. Have you lived in Virginia for the last twelve months? Yes No - Where did you live? _________________________
US state or Foreign country
13. Email address: __________________________________________________________________________________
(This address will be your unofficial e-mail address; you will be assigned an official VCCS e-mail address upon successful
processing of this application.)
14. Emergency Contact Information: ____________________________________________________________________
First Name
Last Name
Relationship
Phone Number
15. Student’s Employer (if employed): ___________________________________________________________________
16. Business phone: ( ________ ) _________ - _____________ ext.: __________
17. Ethnicity: Are you Hispanic or Latino? Yes No
What is your race? (Select any that apply):
White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander
18. Gender: Female Male Not indicated
19. U.S. Citizenship Status:
Native
Naturalized
Alien Permanent A#:______________
Permanent Status: Resident Alien Asylee Refugee
Country of Citizenship? ____________________________________________________________________________
Alien Temporary Visa Type: ______________________________ Visa Expiration Date: _______________________
Country of Citizenship? ____________________________________________________________________________
Not indicated or Not living in the U.S
20. Primary Language: English Other
21. U.S. Military status: No Military Service Spouse Dependent Active duty Active reserves
Inactive reserves National Guard Retired Veteran/VA Ineligible Veteran
Branch:___________________________________ Date of Entry __________________________________________
mm/dd/yy
Do you plan to apply for an F1 or M1 visa? __________________________
(This data to be used for SOC reporting purposes.)
Pay Grade __________ MOS/Rating __________ Current Military Installation ________________________________
Please complete the rest of this form if you plan to pursue a credit program of study or credit classes.
If you selected “non-credit classes” for question # 6 above, you do not need to continue further. Please sign and date the end of the application.
2
RVSD 6/9/2014
Educational History:
22. High School Information
High School (graduated or currently enrolled)
High School __________________________________ Address __________________________________________
City
State
Country (if not USA)
Actual or Anticipated Graduation Date __________________
mm/yy
Diploma Type: Standard Modified Standard General Achievement Advanced Studies Other
(Other includes: Special Diploma, Certificate of Completion, or Don’t Know)
(If you graduated from VA prior to 2003 or in a state other than VA, select Standard.)
Home School (graduated or currently enrolled)
Address __________________________________________ Actual or Anticipated Graduation Date ______________
State
Country (if not USA)
mm/yy
GED
State __________________________ Award Date _________________
mm/yy
No High School diploma or GED
Last Date Attended: _____________________________Highest grade completed: ____________________________
mm/yy
23. Colleges/Universities information. If you have taken any college classes, please list the most recent first.
Indicate any degrees earned in the last column with an A for Associate, B for Bachelor’s, M for Master’s, D for Doctorate,
or P for Professional Degree. If you have not earned a degree, leave the Degrees column blank.
College or University
City, State/Country (if not USA)
Dates Attended (mm/yy – mm/yy)
Degrees Earned
24. Were you suspended or dismissed from the last college attended? Yes No
25. Family Educational Background:
Father’s Highest Education:
Do Not Know Less than High School Attended High School Graduated from High School
Attended College Associate’s Degree Received a Bachelor’s Degree Received a post-Bachelor’s Degree
Mother’s Highest Education:
Do Not Know Less than High School Attended High School Graduated from High School
Attended College Associate’s Degree Received a Bachelor’s Degree Received a post-Bachelor’s Degree
RVSD 6/9/2014
3
Educational Goals:
To be considered for financial aid, students must be in a plan of study that leads to a degree, diploma, or certificate.
(Include specialization/sub-plan, if applicable.)
College Transfer Education
Associate of Arts (AA)
Associate of Science (AS)
Associate of Arts and Sciences (AA&S)
26. I plan to pursue a degree, certificate, or diploma from my community college.
Plan of study/sub-plan______________________________________ (refer to the college catalog).
I do not plan to pursue a degree at this time. Reason for taking classes (check only one):
Upgrading current job skills
Developing skills for new job
Exploring career options
Pursuing personal interest or general knowledge
Currently pursuing degree at another college (transient/visitor)
Planning to pursue a degree at another college (non-degree/transfer)
27. High School Applicants: Dual Enrollment Principal Permission Dual Enrollment/Principal Permission
Career/Technical Education
Associate of Applied Arts (AAA)
Associate of Applied Science (AAS)
I certify under penalty of disciplinary action that all of the information is complete and accurate. I agree to supply the
college with supporting documentation related to my application, if I am requested to do so.
Applicant’s Signature: _________________________________________________ Date: ____________________
Parent/Legal Guardian’s Signature: _______________________________________ Date: ____________________
(If under 18 years of age)
This institution promotes and maintains educational opportunities without regard to race, color, sex, ethnicity, religion, gender,
age (except when age is a bona fide occupational qualification), disability, national origin, or other non-merit factors.
RVSD 6/9/2014
4
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DOMICILE DETERMINATION FORM
All students taking credit classes must complete the
Domicile Determination Form.
Eligibility for in-state tuition is pursuant to
Section 23-7.4, Code of Virginia.
Please contact the college admissions office
if you have any questions.
Mark the domicile category that applies to you below
from choices 1-6. Choose only one category.
1. Self: I am age 24 or older and want to claim eligibility based on my
own domicile.
2. Self: I am under age 24 and want to claim eligibility based on my own
domicile for the following reason(s):
I am a veteran or active duty member of the U.S. Armed Forces.
Both of my parents are deceased and I have no adoptive or legal
guardian.
I have legal dependents other than my spouse.
I am financially self-sufficient.
I am a ward of the court or was a ward of the court until age 18.
I have a bachelor’s degree and I am working on a graduate degree.
I am married.
You may be required to supply “clear and convincing evidence” of
your status.
3. Spouse: I am age 24 or older and want to claim eligibility for in-state
tuition based on my spouse’s domicile.
4. Spouse: I am under age 24 and I want to claim eligibility for in-state
tuition based on my spouse’s domicile.
5. Parent: I am under age 24 and my parents provide more than half of
my financial support and/or claim me as a dependent for tax purposes.
6. Legal Guardian: I am under age 24 and my court-appointed legal
guardian provides more than half of my financial support and/or claims
me as a dependent for tax purposes.
If you marked box 1 or 2, please complete Section A below.
If you marked box 3, 4, 5, or 6, please complete Section B below.
A.
1.
Applicant’s Information
Applicant’s Name:_________________________________________
First
Middle (Full)
Last
B. Parent, Legal Guardian, or Spouse’s Information
1.
Provide the name of the person upon whom you are basing your domicile:
_______________________________________________________
First
Middle (Full)
Last
Date of birth: ____________________________________________
(mm)
(dd)
(yy)
2. Are you a U.S. Citizen?
Yes No
2.
Using the above person’s information, answer the questions below.
Is the above person a U.S. citizen? Yes No
If “No,” is he/she a permanent resident? Yes No
If “Yes,” what is his/her “A number”? __________________________
If “No,” what is his/her immigration status? _____________________
If “No,” are you a permanent resident? Yes No
If “Yes,” what is your “A number”? _____________________________
If “No,” what is your immigration status? ________________________
3.
Are you on active duty in the U.S. Armed Forces? Yes No
If “Yes,” is Virginia listed as the Tax State on your Leave and Earning
Statement? Yes No
Date of Entry: ____________________________________________
mm/dd/yyyy
State
3.
Is the above person on active duty in the U.S. Armed Forces? Yes No
If “Yes,” is Virginia listed as the Tax State on his/her Leave and Earning
Statement? Yes No
Date of Entry: ____________________________________________
mm/dd/yyyy
State
Official Duty Station:_______________________________________
Reporting Date: ______________ Duration of Orders: ____________
mm/dd/yyyy
mm/dd/yyyy
Official Duty Station:_______________________________________
Reporting Date: ______________ Duration of Orders: ____________
mm/dd/yyyy
mm/dd/yyyy
4.
Are you the dependent of an active duty member in the
U.S. Armed Forces?
Yes No
If “Yes,” is Virginia listed as the Tax State on your Leave and Earning
Statement? Yes No
Date of Entry: ____________________________________________
mm/dd/yyyy
State
4.
Is the above person married to an active duty member of the U.S.
Armed Forces?
Yes No
If “Yes,” is Virginia listed as the Tax State on the Leave and Earning
Statement? Yes No
Date of Entry: ____________________________________________
mm/dd/yyyy
State
Official Duty Station:_______________________________________
Reporting Date: ______________ Duration of Orders: ____________
mm/dd/yyyy
mm/dd/yyyy
Official Duty Station:_______________________________________
Reporting Date: ______________ Duration of Orders: ____________
mm/dd/yyyy
mm/dd/yyyy
RVSD 6/9/2014
5
A.
5.
Applicant’s Information
Are you retired from the U.S. Armed Forces? Yes No
Were you discharged from the U.S. Armed Forces? Yes No
If “Yes,” date of discharge/retirement? _________________________
mm/dd/yyyy
B. Parent, Legal Guardian, or Spouse’s Information
5.
Is the above person retired from the U.S. Armed Forces? Yes No
Is the above person discharged from the U.S. Armed Forces? Yes No
If “Yes,” date of discharge/retirement? _________________________
mm/dd/yyyy
Tax State on LES prior to discharge/retirement: __________________
Tax State
Tax State on LES prior to discharge/retirement: __________________
Tax State
6.
Are you the dependent of someone retired from the U.S. Armed Forces?
Are you the dependent of someone discharged from the
U.S. Armed Forces? Yes No
If “Yes,” date of discharge/retirement? _________________________
mm/dd/yyyy
6.
Yes No
Is the above person a dependent of someone retired from the U.S.
Armed Forces? Yes No
Is the above person a dependent of someone discharged from the U.S.
Armed Forces? Yes No
If “Yes,” date of discharge/retirement? _________________________
mm/dd/yyyy
Tax State on LES prior to discharge/retirement: __________________
Tax State
Tax State on LES prior to discharge/retirement: __________________
Tax State
7.
Have you lived in Virginia for the last 12 months? Yes No
If “No,” list address(es) for the last 24 months
From Date _________________ To Date ______________________
Address ________________________________________________
City
State
Country
7.
Has the above person lived in Virginia for the last 12 months? Yes No
If “No,” list address(es) for the last 24 months
From Date _________________ To Date ______________________
Address ________________________________________________
City
State
Country
From Date _________________ To Date ______________________
Address ________________________________________________
City
State
Country
From Date _________________ To Date ______________________
Address ________________________________________________
City
State
Country
8.
For the last 12 months, which of the following applies to you:
8.
paid Virginia income taxes on all earned income
filed as a resident in another state (list state) __________________
filed as a resident in Virginia and as a non-resident in another state
(list state) ____________________________________________
was a resident in a state without income tax (list state) __________
had no taxable income
For the last 12 months, which of the following applies to the above
person:
paid Virginia income taxes on all earned income
filed as a resident in another state (list state) __________________
filed as a resident in Virginia and as a non-resident in another state
(list state) ____________________________________________
was a resident in a state without income tax (list state) __________
had no taxable income
9.
For the past twelve months, have you lived out-of-state, worked in
Virginia, and paid Virginia income taxes on at least $14,500 of earned
income? Yes No
If “Yes,” list state __________________________________________
9.
For the past twelve months, has the above person lived out-of-state,
worked in Virginia, and paid Virginia income taxes on at least $14,500 of
earned income? Yes No
If “Yes,” list state __________________________________________
10. For the past 12 months, have you:
held a Virginia Driver’s license or Virginia DMV ID? Yes No
If “No,” has the applicant held a Driver’s license or DMV ID to any
other state? Yes (List state) ________________________ No
owned or operated a motor vehicle registered in Virginia? Yes No
If “No,” has the applicant owned or operated a motor vehicle registered
in any other state? Yes (List state) _____________________ No
been registered to vote in Virginia? Yes No
If “No,” has the applicant been registered to vote in another state?
Yes (List state) ________________________ No
10. For the past 12 months, has the above person:
held a Virginia Driver’s license or Virginia DMV ID? Yes No
If “No,” has the applicant held a Driver’s license or DMV ID to any other
state? Yes (List state) ________________________ No
owned or operated a motor vehicle registered in Virginia? Yes No
If “No,” has the applicant owned or operated a motor vehicle registered
in any other state? Yes (List state) ______________________ No
been registered to vote in Virginia? Yes No
If “No,” has the applicant been registered to vote in another state?
Yes (List state) ________________________ No
Please note: If you knowingly provide erroneous information to evade payment of out-of-state tuition and fees, you will be charged out-of-state tuition and
fees for each term attended and may be subject to dismissal. Random audits of this information will be performed. I certify under penalty of disciplinary
action that all of the information is complete and accurate. I agree to supply the college with supporting documentation related to my application, if I am
requested to do so.
______________________________________________
Signature of Applicant
Date
Signature of Parent, Legal Guardian (If under 24 years old), or Spouse
_______________________________________________________
Date
RVSD 6/9/2014
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APPLICATION FOR ADMISSION (Northern Virginia Community College)

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Completed 1 December 2020

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