Rec By:

Liaison Use Only

Date:

ID:

____ PCSECHS

SEM/Year ________

APPLICATION FOR ADMISSION TO PCC

Pitt Community College P.O. Drawer 7007 Greenville, NC 27835

To be eligible for enrollment, a high school student must meet the following criteria:

Be enrolled in the PCSECHS

Maintain a weighted GPA of 2.0
Instructions: Type or print in ink, respond to all questions completely, use your legal name, and return completed application
to the PCSECHS College Liaison, Mrs. Erin Harvey. Note: Shaded blocks are for office use only.
Last Name
Jr./Sr. III
First
Middle
Former
Mailing Address

City

County of Legal residence

State of legal residence

Home Telephone
Date of Birth
Ethnicity

State
Country of legal residence

Mobile Telephone
Sex

Are you Hispanic or Latino?

F
Yes

Zip

Social Security Number

Race Select one or more of the following racial categories:

No

American Indian or Alaska Native

Hispanic/Latino: Mexican, Puerto Rican, Cuban, Central or South

Asian

American or other Spanish origin or culture, regardless of race.

Native Hawaiian or Other Pacific Islander

E-Mail Address

Black or African American

Year and term entering 20

Fall

Curriculum for which you are applying

Spring

Enrolling as

White

I plan to attend

Summer

Full-time
Part-time

Freshman
Transfer

Curriculum Code

Returning PCC Student

Long term goal at PCC (check one)

U.S. Citizen

GR

To obtain an Associate Degree, Diploma or Certificate

TR

To take courses to transfer to another college

Yes
Citizenship

Long Term Career Interest: _______________________________________

_____________________________________________________________

No
US Citizen

Permanent Resident Alien

Asylee
Refugee
Non US Citizen

If not a US Citizen, complete the following.

Resident Alien Card Number

Issue Date

Expiration Date

Non Immigrant Visa Type

Issue Date

Expiration Date

Prior address in Home Country

Information supplied on this application is in no way used as a criteria for admission. It is used for institutional statistical purposes and is held in strict confidence. It is the policy
of Pitt Community College not to discriminate against any person on the basis of race, color, handicap, sex, religion, age, or national origin in the recruitment and admission of
students.

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RESIDENCE
Are you a North Carolina resident?
Yes
No
If YES, what is your county of residence?
In what state do you pay State Income Tax?
Enter your drivers license number
In what state was your drivers license issued?
Have you lived in North Carolina continuously for the past 12 months?
If NO, where else have you lived in the past 12 months?
Are you Active Duty Military or a Military Dependent?
If you are active duty, where is your duty station?
If military dependent, where is your sponsors duty station?
Please select one of the two following statements. If the residence status of you or your parents is such that you cannot select either of the
statements, write a letter of explanation and attach it to this application. If in doubt of status, please contact the Vice President of Student
Development.
Resident: This is to certify that I have been a legal resident, or (if under 18) my parents have been legal residents of North Carolina for
the twelve months immediately preceding the date on which I will enroll at Pitt Community College.
Non-Resident: In applying for admission to Pitt Community College, I acknowledge my ineligibility for the resident tuition rate. (A
petition for reclassification may be filed at the end of the qualifying twelve month domicile period.)

Name and Address of persons to contact in case of emergency

Have You Ever Been Convicted of a Felony?

Yes

Relationship

Phone

No

I hereby certify that the information I have given is true to the best of my knowledge. I further understand that falsification or failure to supply the correct
information may be considered grounds for rejections or dismissal.

Applicants signature

Date

Signature of parent/guardian

Date

if applicant is under 18

Additional Information Needed for Student Registration: ____________________________________________________________

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