4/2013
INTERNATIONAL (F1) APPLICATION FOR ADMISSION
HALIFAX COMMUNITY COLLEGE
Admissions Office ● Halifax Community College ● Weldon, NC 27890
Last Name:______________________________________________
Home Telephone ( ) ________________________________
First Name:_______________________________________________
Work/Cell Telephone ( )_________________________________
Middle Name:_____________________________________________
USED FOR STATISTICAL RECORD KEEPING ONLY
GENDER: □ Male □ Female
Former Last Name (Maiden):________________________________
Address:_________________________________________________
City:____________________________________________________
Date of Birth: (MM/DD/YYYY) _______/_________/__________
State:_________________ Zip: __________________________
E-Mail:___________________________________________________
ETHNICITY
Are you Hispanic or Latino? □ Yes □ No
Hispanic/Latino, Mexican, Puerto Rican, Cuban, Central or South
American or other Spanish origin or culture, regardless of race
RACE
□ Native Hawaiian or Other Pacific Islander
□ White
□ American Indian or Alaska Native
□ Asian
□ Black or African American
Academic Goal
□ Obtain Associate Degree, Diploma, Certificate (GR)
□ Take Courses for Personal Interest (PE)
□ Unknown (GU)
□ Enhance My Job Skills In My Present Field of Work (EP)
□ Enhance My Job Skills for a New Line of Work (EN)
CITIZENSHIP AND IMMIGRATION INFORMATION
Country of Citizenship________________________________ Country of Birth_________________________________________
LOCAL (USA) CONTACT INFORMATION
Name: __________________________ Relationship: _______________ Home/Cell No.: _____________ Work No.: ______________
Address: ________________________________________ City: __________________ State: __________ Zip: __________________
Check & complete each educational level that describes you:
Date of Graduation: (Mo/Yr):
□ GED or □ Adult High School
Date of Graduation: (Mo/Yr):
□ Master’s Degree or Higher
Please list ALL colleges and universities previously attended starting with the most recent:
Name of College/University Attended
NOTE: PLEASE DO NOT USE ABBREVIATIONS