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:
High School Graduate
School:
Country/State:
Date of Graduation: (Mo/Yr):
GED or Adult High School
School/Institution:
Country/State:
Date of Graduation: (Mo/Yr):
1 yr College Diploma
Associate Degree
Bachelor’s Degree
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
State or Country
Start Year
End Year
4/2013
Supporting documents are required from all international applicants prior to admissions to Fayetteville Technical
Community College
All Official transcript(s), translated, if applicable
Completed Pre-Entrance Medical form signed by applicant’s
physician
TOEFEL Scores (only official scores will be accepted)
Completed Financial Certificate (Form B)
Preliminary Application (Form A)
Completed Affidavit of Support Form (I-184)
Transfer Clearance Form (if applicable)
Signed F-1 Student Responsibility Agreement Form
I certify that these responses are true to the best of my knowledge and agree to reasonable inquiry where
needed. I am aware that falsification here may result in disciplinary action including denial of admissions or
dismissal after admission.
Signature _____________________________________________________ Date_______________________________
For a complete International Admissions packet, or for more information regarding the international
admissions process, please visit the HCC website at www.halifaxcc.edu/Admissions or Director of
Admissions, James B. Washington, at 252-536-7220.