Please Check One Program of Study
Revised 8/21/17
ASSOCIATE DEGREE - COLLEGE TRANSFER
Associate in Arts A10100
Associate in General Education A10300
Associate in Science A10400
ASSOCIATE DEGREE -2 Years
Advertising & Graphic Design A30100
Associate Degree Nursing RN A45110
Automotive Systems Technology A60160
Business Administration A25120
Computer Information Technology A25260
Criminal Justice Technology A55180
Dental Hygiene A45260
Early Childhood Associate A55220
Human Services Technology A45380
Industrial Systems Technology A50240
Medical Office Administration A25310
Medical Laboratory Technology A45420
Office Administration A25370
Paralegal Technology A25380
*
What courses? ____________________________________
DIPLOMA
- 1 Year
Advertising & Graphic Design D30100
Automotive Systems Technology D60160
Business Administration D25120
Computer Information Technology D25260
Cosmetology D55140
Industrial Systems Technology D50240
Interior Design D30220
Licensed Practical Nurse LPN D45660
Licensed Practical Nurse (LPN) Transitional D45660T
Medical Office Administration D25310
Office Administration D25370
Welding D50420
CERTIFICATE - 1 Year or Less
Advertising & Graphic Design - Computer Graphics C30100C
Advertising & Graphic Design - Graphic Design C30100G
Automotive Systems Technology - AST Basic C60160B
Automotive Systems Technology - AST Advanced C60160A
Basic Law Enforcement Training C55120
Business Administration C25120
Interior Design C30220
Lateral Entry C55430
Phlebotomy C45600
Welding C50420
Industrial Systems Technology C50240
Office Administration C25370
Medical Office Administration-Coding C25310B
HIGHSCHOOLSTUDENTS
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
Application
for Admission
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.
Signature Date
100 College Drive
P.O. Drawer 809, Weldon, NC 27890
Phone (252) 536-4221
Fax (252) 538-4311
Web Address: www.halifaxcc.edu
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
Sex:
Male
Race: White
Hispanic
Day
Female
Black
Asian
Evening
Indian
Other
PLEASE PRINT
List colleges, universities, etc. that you previously attended.
Social Security Number Date of Birth
As shown on social security card:
Last Name
Month Day Year
Name State Dates Attended
Name State Dates Attended
First Name Middle/Former
Mailing Address
Disadvantaged:
If any of the following apply to you, please check.
Other information:
City State Zip Code County
Home Phone ( ) Business Phone ( )
(E) Receive assistance (AFDC, Food Stamps, etc.)
(A) High school dropout (with or without GED)
Indicate Special Needs
(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?
For Statistical Purposes Only (Voluntary)
When Do You Plan To Attend HCC? Check one:
Fall
Spring
Summer
(CR) None of the above
Parent Information
Please check highest degree completed by parent
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
Father:
Never Attended Tenth Grade
Second Grade Eleventh Grade
First Grade Completed High School
Third Grade GED Diploma
Fourth Grade Adult High School Diploma
Fifth Grade One Year Vocational Diploma
Sixth Grade Associate Degree
Seventh Grade Bachelors Degree
Eighth Grade Master’s Degree or Higher
Ninth Grade
Mother:
Never Attended Tenth Grade
Second Grade Eleventh Grade
First Grade Completed High School
Third Grade GED Diploma
Fourth Grade Adult High School Diploma
Fifth Grade One Year Vocational Diploma
Sixth Grade Associate Degree
Seventh Grade Bachelor’s Degree
Eighth Grade Master’s Degree or Higher
Ninth Grade
1.
Yes No Are you a U.S. citizen?
Resi
dency Information
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
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
In addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaska Native Asian Black or African American
Native Hawaiian or other Pacific Islander White
Emergency Contact Information
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name
Date of graduation or withdrawal
Name
County
State
Relationship
Mo/Yr
Mo/Yr
Home Address
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
Telephone
Business Address
Telephone
In case of emergency, permission is granted to seek medical assistance. Yes No
Signature
PLEASE COMPLETE REVERSE SIDE
Sex:
Male
Race: White
Hispanic
Day
Full-Time (12+ hrs)
Female
Black
Asian
Evening
Part-Time (1 - 11 hrs)
Indian
Other
PLEASE PRINT
List colleges, universities, etc. that you previously attended.
Social Security Number Date of Birth
As shown on social security card:
Last Name
Month Day Year
Name State Dates Attended
Name State Dates Attended
First Name Middle/Former
Mailing Address
Disadvantaged:
If any of the following apply to you, please check.
Other information:
City State Zip Code County
Home Phone ( ) Business Phone ( )
(E) Receive assistance (AFDC, Food Stamps, etc.)
(A) High school dropout (with or without GED)
Indicate Special Needs
(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?
For Statistical Purposes Only (Voluntary)
When Do You Plan To Attend HCC? Check one:
Fall
Spring
Summer
(CR) None of the above
Parent Information
Please check highest degree completed by parent
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
Father:
Never Attended Tenth Grade
Second Grade Eleventh Grade
First Grade Completed High School
Third Grade GED Diploma
Fourth Grade Adult High School Diploma
Fifth Grade One Year Vocational Diploma
Sixth Grade Associate Degree
Seventh Grade Bachelor’s Degree
Eighth Grade Master’s Degree or Higher
Ninth Grade
Mother:
Never Attended Tenth Grade
Second Grade Eleventh Grade
First Grade Completed High School
Third Grade GED Diploma
Fourth Grade Adult High School Diploma
Fifth Grade One Year Vocational Diploma
Sixth Grade Associate Degree
Seventh Grade Bachelor’s Degree
Eighth Grade Master’s Degree or Higher
Ninth Grade
1.
Yes No Are you a U.S. citizen?
Resi
dency Information
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
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
In addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaska Native Asian Black or African American
Native Hawaiian or other Pacific Islander White
Emergency Contact Information
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name
Date of graduation or withdrawal
Name
County
State
Relationship
Mo/Yr
Mo/Yr
Home Address
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
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
DIPLOMA - 1 Year
Advertising & Graphic Design D30100
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
Advertising & Graphic Design - Graphic Design C30100G
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
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?
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.
Signature Date