Dual Admission Partnership Agreement - Intent to Enroll
Please print clearly.
NAME
LAST FIRST MIDDLE SUFFIX
Othernamespreviouslyused
DSCCIDNumber D________________________
GENDER: (___)Male (___)Female
PERMANENT ADDRESS
Number & Street (P.O. Box not allowed)
City State Zip County
MAILING ADDRESS
Number & Street (If different from Permanent Address)
City State Zip County
HOME PHONE NUMBER (
) CELL PHONE NUMBER ( )
E-MAIL ADDRESS
DATE OF BIRTH / /
BIRTHDATE
/ /
GENDER
Male
Female
ETHNICITY/RACE
DO YOU CONSIDER YOURSELF TO BE HISPANIC/LATINO/SPANISH ORIGIN?
____Yes ____No
IN ADDITION, 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 Pacific Islander
CITIZENSHIP INFORMATION
COUNTRY OR STATE OF BIRTH
ARE YOU A UNITED STATES CITIZEN? _____ Yes _____ No If no, indicate country of citizenship
Visa Type
Resident Alien (Please include copy of Resident Alien Card)
ARE YOU A RESIDENT OF TENNESSEE? DATE OF TENNESSEE RESIDENCY? / /
I Expect to Graduate from DSCC at the End of (Semester/Year)
/
I Expect to Graduate from DSCC in the following program of study
Semester/Year You Plan to Attend UT Martin
/ Choice of Major at UT Martin
Have you ever been arrested and convicted for a criminal offense?
Yes No
If yes, what offense did you commit? (On a separate sheet of paper, please explain the circumstances.)
RELEASE NOTIFICATION: Dyersburg State Community College and The University of Tennessee at Martin will share and release
information about Dual Admission Partnership students. Your signature below allows for the release of this information. I certify that the
information above is true and complete to the best of my knowledge. I understand that the eligibility for the Dual Admission Partnership
requires compliance with the provisions of the program, including completion of the associate degree at DSCC. I understand that
participation in this program may be denied if any of my application information is found to be incomplete or inaccurate. I agree to
comply with the provisions of the Dual Admission Partnership program.
___________________________________________________________SIGNATURE ____________________________ DATE
