Fillable Application for Admission Contact Information (Staff use only) (New River Community and Technical College)

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Application for Admission Contact Information (Staff use only) (New River Community and Technical College)

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Contact Information
NAME: ___________________________________________________________________________________________________
Last First Middle Name
List any former last name(s) you have used for work or school: _______________________________________________________
SOCIAL SECURITY NUMBER: _________ – _______ – _________ BIRTH DATE: ____________________________________
HOME PHONE: ( ____ ) ______________ WORK PHONE: ( ____ ) ______________ CELL PHONE: ( ____ ) ______________
MAILING ADDRESS: ______________________________________________________________________________________
Street or P.O. Box where you receive your mail
__________________________________________________________________________________________________________
City State Zip/Postal Code County
CURRENT E-MAIL ADDRESS (you will receive a College email account): ________________________________________________________________
Emergency Contact Information
Contact: __________________________________________ Relationship: ___________________________________________
Telephone: Home: ( _____ ) _________________ Work: ( _____ ) _________________ Cell: ( _____ ) _________________
Demographic Information
Gender: Male Female Marital Status: Single Married Widow/Widower Divorced Separated
What is your ethnicity? Hispanic or Latino Not Hispanic or Latino
Regardless of your answer to the prior question, please select one or more of the following races that best describe you*:
American Indian or Alaska Native Asian Black or African American
Hispanic or Latino Native Hawaiian or Other Pacic Islander White
*Required for federal reports by Civil Rights Act of 1964. Not used for admission decision.
Do you have a disability or special needs that you would like to self-identify for follow-up? ________________________________
__________________________________________________________________________________________________________
Do you have current or prior military service (includes veteran, active duty, National Guard, and Reserve)? Yes No
Are you a survivor, dependent or a spouse of a 100% disabled veteran or deceased veteran? Yes No
If yes, will you receive their benets? Yes No For required forms visit http://www.newriver.edu/future-students/veterans-benets
Citizenship and Residency Information
US Citizen: Yes No If no, are you a Permanent Resident? Yes No (A copy of your Permanent Resident “Green” Card is required)
Are you a West Virginia Resident? Yes No How long have you resided in West Virginia? __________________________
Have you resided in West Virginia for the entire past 12 months? (other than as a college student) Yes No
Location and Program Information
Where will you take the majority of classes? Planned Entry Year: ____________ and semester
Advanced Technology Center Nicholas County Campus Fall (August) 1st Summer (May)
Greenbrier Valley Campus Raleigh County Campus Special Session (Dec.-Jan.) 2nd Summer (July)
Mercer County Campus Other: ___________________ Spring (January)
Student Status applied for: Program/Major*: ____________________________________
First-Time Freshman High School Student Non-Degree Seeking or Advanced Skill Set Certicate
Returning/Readmission Special (not eligible for nancial aid)
Transfer (Non-Degree/Non-Certicate Seeking) Certicate of Applied Science
Transient/Visiting Associate of Science
Associate of Applied Science
*A complete list of certicate and degree programs are available at http://www.newriver.edu/current-students/academics/degree-and-certicate-programs
New River Community and Technical College Form SS-0001: Revised 6/17 Application for Admission Page 1 of 2
Application
for Admission
Student ID:
(Staff use only)
High School/High School Equivalency (HSE) and Placement Information
Names of School(s) City/State Dates Attended Diploma Graduation Date
From what high school or HSE center did or will you graduate? FROM TO
Yes No
Yes No
Do you have Edge Credit (WV students only)?
Yes No To request your transcript visit http://careertech.k12.wv.us/edge/takingEdge.html
What placement test(s) have you completed?
ACT SAT Accuplacer Compass Date Completed: __________
Note: Placement testing is an admission requirement, used for evaluation and placement. Results will not determine admission. If you have not
taken the ACT, SAT, Accuplacer or Compass (from a WV high school) within 5 years from the date of application, contact the Education Counselor
at your location to schedule testing.
Advanced Technology Center Greenbrier Valley Campus Mercer County Campus Nicholas County Campus Raleigh County Campus
(304) 929-6735 (304) 647-6591 (304) 818-2014 (304) 883-2465 (304) 929-5005
Previous College
Degree Graduation Total
Names of School(s) City/State Dates Attended Earned Date Credits
FROM TO
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Note: You must have your high school, HSE program, and all prior colleges submit your official transcripts to the New River CTC Office
of Admissions at the location you will attend if you are degree or collegiate certificate seeking. Transcript(s) must be submitted in their
sealed envelope even if you have withdrawn from all coursework.
How did you learn about New River CTC?
Declaration and Signature
Have you ever been convicted of a felony or do you have any felony charge(s) pending against you at this time? Yes No If yes, please
attach an explanation.
Have you ever been convicted of a misdemeanor?
Yes No If yes, please attach an explanation.
Note: A felony or misdemeanor conviction does not automatically disqualify applicants for college admission but may prevent licensure and/or the
ability to complete specic programs. Students should speak with the Program Director and/or Instructor for guidance.
By signing below, I declare that the information I have supplied on this application is complete, truthful and correct. I further authorize New River
Community and Technical College personnel to verify the information given on this application. I understand that omitting and/or providing false
information may lead to dismissal.
Signature Date Signed
Mail to: New River Community and Technical College, Ofce of Admissions
Use the address below for the location where you will take the majority of classes. This is where you will register for classes and receive nancial
aid counseling.
Advanced Technology Center Greenbrier Valley Campus Mercer Co. Campus Nicholas Co. Campus Raleigh Co. Campus
P.O. Box 307 653 Church Street 1001 Mercer Street 6101 Webster Road 280 University Drive
Ghent, WV 25843 Lewisburg, WV 24901 Princeton, WV 24740 Summersville, WV 26651 Beaver, WV 25813
(304) 929-3315 (304) 647-6565 (304) 818-2012 (304) 883-2437 (304) 929-5469
OR e-mail to: admissions@newriver.edu
New River Community and Technical College is accredited by the North Central Association of Colleges and Schools and is approved by the West
Virginia Council for Community and Technical College Education and the West Virginia Board of Education. New River CTC does not discriminate
on the basis of race, color, national origin, ancestry, sex, sexual orientation, age, religion, blindness or disability in its educational programs or in
admission to, access to, treatment in, or employment as required by applicable state and federal law. The following individual has been designated
to handle inquiries regarding the College’s non-discrimination polices relating to disabilities or sex discrimination: Leah Taylor, VP Administrative
Services and Student Services, 304-929-6701, ltayor@newriver.edu (Employees/Visitors/Third Parties/Students).
New River Community and Technical College Form SS-0001: Revised 6/17 Application for Admission Page 2 of 2
Agency
Career Focus Magazine
Friend/Family member
High School
New River CTC Faculty/Staff
Newspaper
Radio
Recruiter
Social media
Television
Website (www.newriver.edu)
Other: ___________________
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Application for Admission Contact Information (Staff use only) (New River Community and Technical College)

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Completed 27 July 2020

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