Southeastern Technical College is an Equal Opportunity Institution
SWAINSBORO 346 Kite Road • Swainsboro, Georgia 30401 • Phone (478) 289-2200 • Fax: (478) 289-2263
VIDALIA 3001 East First Street • Vidalia, Georgia 30474 • Phone (912) 538-3100 • Fax (912) 538-3156
Personal Data: Please Print Neatly Ineligible and/or incomplete applications will not be processed.
Social Security Number _________________________________________________ Date of Birth _____/_____/______
Last Name _________________________ First Name _______________________ Middle Name __________________
Mailing Address __________________________________ City __________________ State ______ Zip Code ________
County ________________________ Email _____________________________________________________________
Cell Phone ____________________________________ Home Phone ________________________________________
Statistical Data (This information is required for purposes of reporting to the federal government and will not be
used in determining admission status.)
Race: Are you Hispanic/Latino? ____ Yes ____ No Gender: ____ Male ____ Female
Ethnic/Racial Group: Please select one or more races from the following five racial groups:
_____ American Indian or Alaska Native ____ Asian ____ Native Hawaiian or other Pacific Islander
_____ Black or African American ____ White
Did your father graduate from college? ___ Yes ___ No Did your mother? ___ Yes ___ No
Program Information Check your program interest or list on the line provided
____ ACCEL/Core Classes ____ Criminal Justice ____ Fish & Wildlife ____ Nurse Aide ____ Welding
Other: (Refer to Program List for all STC Programs) _______________________________________________________
Semester/Year to Begin: (List year) Fall: Aug/_____ Spring: Jan/_____ Summer: May/_____
Campus: _____Vidalia STC _____ Swainsboro STC
Residency Information: Are you a US citizen? _____ Yes _____ No
If no, do you have a VISA? _____ Yes _____ No
If NOT, what is your country of birth/citizenship? __________________________________________________________
Educational Data: Graduation Year: _______ Current High School __________________________________________
Have you taken classes with another college? ___ Yes ___ No If so, where? ________________
Emergency Contact: Name _____________________________________________ Phone ______________________
In compliance with federal law, Southeastern Tech is required to provide all prospective
students with the opportunity to request data on crimes committed on our campus and our
College safety and security policies. This information can be obtained from the Southeastern
Technical College Catalog and Student Handbook on our website. Go to
www.southeasterntech.edu, move your mouse over the Student Affairs tab, click on the
Catalog & Handbook link and then on Campus Security. Prospective students who wish to
obtain a copy of this report and who do not have access to the Catalog and Handbook on the
Internet may obtain a copy by contacting: Dr. Barry Dotson, Vice President for Student Affairs.
As set forth in its student catalog, Southeastern Technical College does not discriminate on the basis of race, color, creed,
national or ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or
citizenship status (except in those special circumstances permitted or mandated by law). The following person(s) has
been designated to handle inquiries regarding the nondiscrimination policies:
An individual with disabilities requiring assistance with publications, accommodations or activities of this technical
college should contact: Helen Thomas, Special Needs Specialist, ADA/Section 504 - Equity - Title IX (Students) -
OCR Compliance Officer, Office 165, PH: (912) 538-3216 • hthomas@southeasterntech.edu
An individual with questions or concerns about our nondiscrimination policy on the basis of sex in education programs
and/or activities should contact: Lanie Jonas, Director of Human Resources, Title VI - Title IX (Employees) - EEOC
Officer, Office 138B, PH: (912) 538-3230 ljonas@southeasterntech.edu
Inquiries concerning the application of these policies and procedures may be directed to the individuals listed above
at: Southeastern Technical College, 3001 East First Street, Vidalia, GA 30474 • (912) 538-3100 • 1-800-255-0056
Pursuant to O.C.G.A. 16-10-20, it is a felony to make a false statement on any document. In
addition, making a false statement on this application may result in your dismissal from the
AUTHORIZATION: I give Southeastern Technical College permission to contact me at the telephone numbers I have
provided via any means, including text message or voice.
I intend to abide by the rules and regulations of Southeastern Tech. By signing and submitting this application and upon
my admission to Southeastern Technical College, I understand that my name, quotations, and photographic likeness
including video footage may be used in all forms of media for advertising, trade, and any other lawful purposes on behalf
of Southeastern Technical College or the Technical College System of Georgia and that I will not receive, now or in the
future, any compensation for this usage. I also understand that my name, quotations, and photographic likeness may be
gathered from and posted to STC’s social media sites and website. I also realize that during my training at STC,
photographs may be taken of me for use in promoting STC. I give my permission for the release of directory information
as defined in the Catalog and Student Handbook. Unless I notify Admissions by filling out a Directory Information
Exclusion Form, I give permission for the above to be done.
Applicant’s Signature ___________________________________ Date _________________
Date Received __________________________ Test Date _____________________ Receipt No. __________________