Johnston Community College: Page 1

NAME AND ADDRESS

Student Name

Last name:*
First name:*
Middle name:
Suffix:
Preferred first name:

* = Required

Mailing Address

Street:*
City:*
U.S. state/territory:*
Zip code:
Country:
Telephone Number where you can best be reached:*	(###) ###-####
Work telephone:	(###) ###-####
Cellular telephone:	(###) ###-####

Campuses rely on e-mail to communicate updates about the application status. Please make sure to provide an e-mail address for an account that you check frequently.
E-mail Address:*
E-mail Verification:*

* = Required

Applicant Information

Social Security number:

###-##-####

Reenter your Social Security number
(for verification):

###-##-####

The Social Security number is requested by the institution solely for administrative convenience and record-keeping accuracy, and is required only to provide a personal identifier for the internal records of this institution.

Date of birth:*

mm/dd/yyyy

The following information will not be used in a discriminatory manner. This data is used for statistical purposes only.

Gender:*

Ethnicity

Are you Hispanic or Latino?

Hispanic/Latino: Mexican, Puerto Rican, Cuban, Central or South American or other Spanish origin or culture, regardless of race

Race

Select one or more of the following racial categories:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Citizenship

Select the appropriate designation:*
If you selected "US Citizen", please skip to the Emergency Contact Section.
If non-U.S. citizen, select country of citizenship:
Permanent Resident number:
Visa type:
Non-immigrant visa number:
Issue date:	mm/dd/yyyy
Expiration date:	mm/dd/yyyy
Have you been assigned an INS SEVIS number?
If yes, enter INS SEVIS number:

* = Required

Emergency Contact

Name:
Telephone:	(###) ###-####
Emergency Notification
Family physician:
Telephone:	(###) ###-####

* = Required

Family Information

Father's Education Level:
Mother's Education Level:

* = Required

ENROLLMENT INFORMATION

Enrollment term:*
Entrance status:*

Do you plan to enroll:*
Do you plan to attend during:*

Choose the program of study/major which you are interested in pursuing:*

Education goals (select what is your primary goal):*

Employment status while enrolled:*
Employer Name:
Street:
City:
U.S. state/territory:
Zip Code:
How did you learn about the college?*
I am currently expelled or suspended from another college or university:*
If yes, select �Academic� or �Disciplinary�:

* = Required

EDUCATIONAL INFORMATION

Most Recent High School

High school:*
Type:*
Street:*
City:*
County:	(NC residents only)
U.S. state/territory:*
Country:
Anticipated Graduation date or last date attended:*	mm/yyyy
High school track:*
Did you graduate from high school?*

* = Required

Education History

Highest educational level completed that best describes you:*