Fillable APPLICATION FOR ADMISSION/READMISSION (Jackson State Community College)

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APPLICATION FOR ADMISSION/READMISSION (Jackson State Community College)

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The APPLICATION FOR ADMISSION/READMISSION (Jackson State Community College) form is 2 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 106 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Jackson State Community College

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www.jscc.edu
In case of emergency, contact: Phone ( )
Please print. Complete all items before signing and submitting to JSCC Admissions for complete and accurate processing.
Social Security Number:
Name
Date of Birth ____ /____ /____
Last
First
Middle/Previous
We request your completion of the following for reporting purposes only. This information will not be used to
discriminate against any applicant in the admission decision:
Yes No
Male Female
Do you consider yourself to be Hispanic/Latino/Spanish origin?
Select one or more of the following racial categories to describe yourself:
White Black or African American
Asian
American Indian Alaskan Native
Native Hawaiian or other Pacifi c Islander
United States Citizenship? (check one) U.S. Citizen (If not a citizen, provide all information requested below)
Permanent Resident Foreign Citizen
Permanent Resident Alien No.
Visa Type Native Language
All applicants whose native language is not English must submit an acceptable score on theTest of English as a Foreign Language (TOEFL). Non-citizens must also provide their visa or alien registration card/passport.
Student Classifi cation: Check One:
New Student
Transfer Studen
t Readmission Transient
(one term only)
High School Student
Dual Enrollment Joint Enrollment Academically Gifted
If a social security number is unavailable, a student ID number
will be assigned. Applicants must retain this number for access
to their fi les. For added security, a college-wide ID number is
assigned to each student.
Have you lived in Tennessee continuously since birth?
Yes No
If no, how long have you lived in Tennessee?
State your reason for moving to Tennessee:
APPLICATION FOR ADMISSION/READMISSION
Are you applying for fi nancial aid? Yes No
Are you applying for veteran’s benefi ts?
Yes No
Degree Seeking at JSCC:
Yes No (18 hr. limit) (list major) _________________________
Certifi cate Seeking: Yes
No (list name)
Taking courses for: Credit Audit
I am applying for:
Fall
Summer
Spring
Year _________
City State
Zip
Home Phone
( )
Work Phone
( )
Cell Phone
( )
E-mail Address
We will use this e-mail to correspond with you, but will not share with any third parties.
County
Address
This application cannot be submitted electronically. Please print, sign and fax or mail to Admissions.
This application cannot be submitted electronically. Please print, sign and fax or mail to Admissions.
Previous college/university education:
Name of Previous College(s) City & State Dates of Attendance Degree-Yes/No Name Under Which You Were Enrolled
Did you graduate from high school? Date Graduated
School Name City State
Previous School Information – Check and complete all that apply.
Academic Fresh Start Request -
Readmission and transfer students who have been separated from any
institution of higher education for at least four years and are interested in the Academic Fresh Start procedure, which disregards
all previous college coursework, should check this box.
Application Certifi cation and Agreement:
If you are accepted as a student, there are certain performance tests you will be required to take during your academic
career. It is a requirement of admission that you agree to take any tests deemed necessary by JSCC. In those instances where
tests are administered by an external entity, you hereby agree that the results of such tests be released to the institution. If
you are under 21 years of age and are required by policy to complete the placement tests, your scores on these tests and
course placement may be reported to your high school for research purposes. Any test scores will be treated confi dentially as
required by law.
I understand that it is my responsibility to obtain offi cial transcripts from each institution attended to support my application
for admission. JSCC accepts no formal responsibility for delivery of transcripts by other schools.
Further, if I am admitted to Jackson State, I agree to abide by the rules and regulations of the College.
I understand that withholding information requested
on this application or giving false information may make me ineligible
for admission to
the college or subject to dismissal. With this in mind, I certify that the above statements are correct and
complete.
Signature:
Date:
What is your educational goal for attending JSCC?
Complete associate degree at JSCC Take course for job improvement
Take courses to transfer to another school or program Personal growth
Other: (please list)
Yes No
NOTE: Students who graduated with special education diplomas or certi� cates of attendance are not admissible without a GED.
If you did not graduate from high school, did you earn the GED/HiSET? Yes
No
If yes, when?
Location completed?
site
etatsytic
Selective Service Statement:
All male USA citizens between 18 and 26 years old must have registered for selective service prior to registering for classes.
This requirement does not apply to veterans and others exempt by federal law. Indicate whether or not you have registered
for the U.S. draft:
Yes No
Exempt – List Reason:
This application cannot be submitted electronically. Please print, sign and fax or mail to Admissions.
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APPLICATION FOR ADMISSIONREADMISSION (Jackson State Community College)

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Completed 27 July 2020

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