major code: 396 term: ______________ date received: ______________ date entered: _____________
Substance Abuse Intervention Specialist AAS
1. Social Security Number: Upon submission you must provide your SSN to the College, you will receive information on
how to provide this upon receipt of this completed application.
2a. Name: _____________________________ _____________________________ ____________________________
Last First Middle
Please list any other name you have used for work or school, including maiden name:
2b. Please check one: Miss Mrs. Mr. Ms. 2c. Suffix: _____________________________
3. Address: ___________________________________ ______________________________ _______ ____________
Street City State Zip Code
4. County: _____________________________ 5. Nation (if not U.S.): ________________________________
6. Telephone: ( ______ ) ______- ______ Cell Phone†: ( ______) ______- ______
7. E-mail address: ____________________________________
8a. Ohio Residents: Are you a resident of Belmont, Harrison, Jefferson, Monroe, Columbiana, Mahoning or Trumbull
county? (Reciprocity Rate) Yes No
8b. Pennsylvania Residents: Are you a resident of Allegheny, Beaver, Butler, Greene, or Washington county?
Yes No
8c. Ohio Residents: Are you a resident of Washington County? (Metro Tuition Rate) Yes No
9. Gender: Male Female 10. Birth date: ______ / ______ / ______
11. Are you a United States Citizen? Yes No
12. Are you a green card holder (Permanent Resident)? Yes No
13. Has either of your parents received a bachelor’s degree? Yes No
14a. Are you Hispanic or Latino? Yes No
14b. Check all that apply: American Indian or Alaskan Native Asian Black/African American
Native_Hawaiian/other Pacific Island White Unknown
15. High School Completion Status: High school graduate TASC or GED™ Home Schooled
Did not graduate high school/no TASC or GED™
16. High School (GED™ /TASC) Graduation YEAR? _________
High school: _____________________________ City/State _____________________________
17a. If you have ever attended any other college for at least one day, please list each college.
Failure to list all colleges may result in suspension. Do not abbreviate college names.
College: __________________________________________________________________________
City & State: _______________________________________________________________________
Last Date Attended: ____________________ Degree Earned: _______________________________
If more space is needed, attach another sheet.
17b. Were you dismissed from any institution for disciplinary reasons? No If yes, list institution:
18a. Have you previously attended WVNCC? Yes No
18b. If so, did you attend WVNCC prior to 1990? Yes No
19. Have you lived at your current address for at least one year? Yes No
If less than one year, please list all addresses used in the past 12 months and the length of time at each.
from _____________________ to _____________________
from _____________________ to ____________________
20a. Are you a registered Sex Offender? Yes No
20b. Do you have current or prior military service? Yes No
(includes Veteran, Active Duty, National Guard and Reserve)
Please specify:
Veteran Active Duty Service Member National Guard Reserve
20c. Are you an international student? Yes No
Citizenship Country: _____________________________ Country of Birth: ________________________________
21a. I certify that all the information provided in this application is complete and correct to the best of my knowledge. I understand that any
false information or omission of information relating to residency, citizenship and previous college attendance is cause for suspension from West
Virginia Northern Community College. I will acquaint myself with and abide by the student Code of Conduct, including compliance with the Drug-
Free Schools and Communities Act, and other requirements governing the academic and social standards of West Virginia Northern Community
22b. I agree as part of the Substance Abuse Intervention Technician Advanced Skill Set to be informed about my academic standing at the
College and continued eligibility for the program at any time throughout the program. This signed statement is my FERPA release as it relates only
to this program. I have attached my signed "student commitment letter” to this application.
______________________________________________ __________________________
Enter Full Name Date
Students must pass placement exams for Reading/English OR successfully complete ENG 097 prior to admission to the program and have a 2.0
cumulative GPA in college or high school coursework. Further, because of the nature of this program and the requirements of this selective
admissions program, students must meet background and/or drug testing requirements of placement agencies for practicums/clinical
experiences/internships as specified by the agency or agencies prior to beginning practicums/clinical experiences/internships and/or employment.
Students who do not maintain satisfactory performance & progress in this program as evidenced by minimum grades of "C" in all required courses
and maintaining a cumulative GPA of 2.0 may lose their eligibility for financial assistance and to continue in the program."
GENERAL ADMISSION POLICY: West Virginia Northern Community College is an “open admissions” college, admitting all students but not
necessarily into a program of immediate choice. Early entrance and continuing education applicants should request specific applications.
ADMISSION PROCEDURES: The following items are to be submitted by all applicants:
West Virginia Northern Community College application form.
Standardized placement test scores, if available. (i.e.: ACT, SAT, COMPASS Scores)
High school transcript and/or GED™ or TASC scores. IMPORTANT: Applicants who graduated from high school or passed their GED or
TASC more than five (5) years. Prior to admission and/or have earned 30 or more semester hours of credit at a regionally accredited
institution are exempt from this requirement.
Official transcripts from all postsecondary educational institutions previously attended, sent directly from the Registrar’s office of the
previous institution or institutions.
IMPORTANT INFORMATION FOR ALL STUDENTS: If you have ever been convicted of a felony or misdemeanor for any reason, State or National
credentialing boards may deny you a license, or agencies which do criminal background checks on potential employees (or student interns) may
deny you employment or placement in certain settings, even if you have completed all academic requirements. If you have been convicted of a
felony or misdemeanor, speak with your faculty advisor. Selective admissions programs may have additional requirements.
FINANCIAL AID: Financial aid IS NOT available for this program including student loans. Stipends for part-time and full-time students are available
under this program, in addition to other forms of financial aid
VETERANS: Veterans planning to receive VA educational benefits should contact the Veterans Coordinator for institutional forms.
SELECTIVE SERVICE: All male students under age 26 must be in compliance with the Military Selective Services Act. Financial Aid recipients have
additional requirements.
DISABILITIESERVICES: Students in need of special accommodations should contact the Academic Support Center Accessibility Office and provide
appropriate documentation.
INTERNATIONAL STUDENTS: Contact the Admissions Office to understand additional requirements.
† OPT-IN NOTICE: By providing your cell phone number, you agree to receive text based communication from the institution to which you have indicated an interest in applying
and from the West Virginia Higher Education Policy Commission and the West Virginia Council for Community and Technical College Education, otherwise known as the College
Foundation of West Virginia. Your information will not be shared with institutions other than those to which you have indicated interest, nor will your information be utilized by
vendors or other third-party organizations. Standard_text messaging rates apply and you are responsible for any costs incurred in receiving texts. You may also opt-out at any
time by replying to any text sent.
Equal Opportunity Policy West Virginia Northern Community College, pursuant to the requirements of Titles IV, VI, VII of the Civil Rights Act of 1964, Title IX of the Educational
Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, does not discriminate against applicants, employees, or students on
the basis of race, color, religion, sex, disability, age, gender, ancestry, marital or parental status or national origin in its employment policies and/ or educational programs or
activities, including admissions to such.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant #
T26HP394640100 “Opioid Impacted Family Support Program”. This information or content and conclusions are those of the author and should not be construed as the official
position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”
Inquiries concerning this rule should be directed to , Stephanie Kappel, who is designated coordinator for Title IX and Section 504. Her telephone number is 304-214-8801 and
her office is located in Room 126, B&O Building, Wheeling campus. Her email address is
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant
#T26HP394640100 “Opioid Impacted Family Support Program”. This information or content and conclusions are those of the author and should not be construed as the official
position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”