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Revised 6/18/18 (Halifax Community College)

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Application for Admission
100 College Drive
P.O. Drawer 809, Weldon, NC 27890
Phone (252) 536-4221 Fax (252) 538-4311
Web Address: www.halifaxcc.edu
Revised 6/18/18
Sex:
□ Male
Race:
□ White
☐
Hispanic
□ Day □ Full-Time (12+ hrs)
□ Female
□
Black
☐
Asian
□
Evening
□
□
Indian
☐
Other
PLEASE PRINT
Social Security Number Date of Birth
As shown on social security card:
Last Name
Month Day Year
First Name Middle/Former
Mailing Address
City State Zip Code County
Home Phone ( ) Business Phone ( )
For Statistical Purposes Only
(Voluntary)
When Do You Plan To Attend HCC? Check one:
□
Fall
□
Spring
□
Summer
Employment Information
1 ☐ Retired 5 ☐ Employed 11 - 20 hours per week
2 ☐ Unemployed - not seeking employment 6 ☐ Employed 21 - 39 hours per week
3
☐ Unemployed - seeking employment 7 ☐ Employed 40 or more hours per week
4
☐ Employed 1 - 10 hours per week
Long Term Goal
1
☐ To obtain an associate degree, diploma, or certificate 4 ☐ To take courses to transfer to another college
2
☐ To enhance my job skills in my present field of work 5 ☐ To take courses for personal enrichment or
3 ☐ To enhance my employment skills for a new field of work interest
Residency Information
1.
☐
Yes
☐
No Are you a U.S. citizen?
2.
☐
Yes
☐
No Are you a resident of North Carolina?
3.
☐
Yes
☐
No
Have you lived in North Carolina for the past 12 months?
Since
Month Year
If not, why?
List dates outside North Carolina:
From: To: State
Educational Information
High School last attended
Name
County
State
Date of graduation or withdrawal
Mo/Yr
Mo/Yr
Check Highest Degree Completed:
□ Currently enrolled in high school
□ GED Certificate
Place State
Month Year
Circle Highest Grade Completed: 8 9 10 11 12 over 12
□ 12 High School Diploma
□ 13 Adult High School
□ 14 Post High School Vocational (1-year diploma)
□ 15 Assoc./Assoc. in Applied Science (2-year)
□ 16 Bachelor’s Degree
□ 17 Masters or higher
☐
Never Attended
☐
Tenth Grade
☐
Never Attended
☐
Tenth Grade
☐
Second Grade
☐
Eleventh Grade
☐
Second Grade
☐
Eleventh Grade
☐
First Grade
☐
Completed High School
☐
First Grade
☐
Completed High School
☐
Third Grade
☐
GED Diploma
☐
Third Grade
☐
GED Diploma
☐
Fourth Grade
☐
Adult High School Diploma
☐
Fourth Grade
☐
Adult High School Diploma
☐
Fifth Grade
☐
One Year Vocational Diploma
☐
Fifth Grade
☐
One Year Vocational Diploma
☐
Sixth Grade
☐
Associate Degree
☐
Sixth Grade
☐
Associate Degree
☐
Seventh Grade
☐
Bachelor’s Degree
☐
Seventh Grade
☐
Bachelor’s Degree
☐
Eighth Grade
☐
Master’s Degree or Higher
☐
Eighth Grade
☐
Master’s Degree or Higher
☐
Ninth Grade
☐
Ninth Grade
☐
American Indian or Alaska Native
☐
Asian
□ Black or African American
☐
Native Hawaiian or other Pacific Islander
☐
White
List colleges, universities, etc. that you previously attended.
Name State Dates Attended
Name State Dates Attended
If any of the following apply to you, please check.
Disadvantaged:
(E) ☐ Receive assistance (AFDC, Food Stamps, etc.)
(A) ☐ High school dropout (with or without GED)
Indicate Special Needs
Other information:
(Y) ☐ English as second language
(H) ☐ Homemaker (has not recently worked outside the home)
(S) ☐ Single Parent
(FG) ☐ Are you the first person in your family to attend college?
(CR) ☐ None of the above
Parent Information Please check highest degree completed by parent
Father: Mother:
Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and our own college/
university communities, to describe the racial/ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to
answer the following two questions:
Do you consider yourself to be: Hispanic/Latino ☐ Yes ☐ No
In addition, select one or more of the following racial categories to describe yourself:
Emergency Contact Information
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name
Relationship
Home Address
Telephone
Business Address
Telephone
In case of emergency, permission is granted to seek medical assistance. ☐ Yes ☐ No
Signature
PLEASE COMPLETE REVERSE SIDE
Please Check One Program of Study
ASSOCIATE DEGREE - COLLEGE TRANSFER
□ Associate in Arts A10100
□ Associate in General Education A10300
□ Associate in Science A10400
□ Associate in Science A10400 (LPN-RN) A45110T
ASSOCIATE DEGREE - 2 Years
□ Associate Degree Nursing RN A45110
□ Automotive Systems Technology A60160
□ Business Administration A25120
Cosmetology A55140
□ Criminal Justice Technology A55180
□ Dental Hygiene A45260
□ Early Childhood Associate A55220
□ Human Services Technology A45380
□ Industrial Systems Technology A50240
□ Information Technology A25590
□ Medical Office Administration A25310
□ Medical Laboratory Technology A45420
□ Office Administration A25370
□ SPECIAL STUDENTS (Not declaring a degree or only
online classes at HCC. This includes students who intend to
take courses and transfer to another college) T90990
What courses?
DIPLOMA - 1 Year
□ Automotive Systems Technology D60160
□ Business Administration D25120
□ Computer Information Technology D25260
□ Cosmetology D55140
□ Industrial Systems Technology D50240
□ Licensed Practical Nurse LPN D45660
□ Medical Office Administration D25310
□ Office Administration D25370
□ Welding D50420
CERTIFICATE - 1 Year or Less
□ Automotive Systems Technology - AST Basic C60160B
□ Automotive Systems Technology - AST Advanced C60160A
□ Basic Law Enforcement Training C55120
□ Business Administration C25120
□ Lateral Entry C55430
□ Phlebotomy C45600
□ Welding C50420
□ Industrial Systems Technology C50240
□ Office Administration C25370
HIGH SCHOOL STUDENTS
□ Early College A10100EC
□ Career and College Promise (CCP) **
** CCP applicants are also responsible for completing:
1) Eligibility Form
2) Registration Application Form
CCP students should see their high school counselor for
application details
Make sure the following information is in your file: a) Photocopy of your social security card
b) All official transcripts
Halifax Community College welcomes students and employees without regard to race, color, national origin,
religion, sex, age, or disability.
I understand that by changing my major, it may affect my financial aid status.
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Revised 61818 (Halifax Community College)

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Completed 1 October 2020

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