Johnston Community College: Page 1

Residency Determination

Before applying you must complete the Residency Determination. RDS will provide you with a Residency Certification Number (RCN) and a summary of the information you entered. Your RCN will be required to complete your JCC admissions application. To determine residency, link to Residency Determination

RCN Number: *

NAME AND ADDRESS

Student Name

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

* = Required

Permanent Address

Street:*
City:*
U.S. state/territory:*
Zip code:
Country:
Int'l postal code:
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

Mailing Address

If your mailing address is the same as your permanent address listed above, copy it here.
Street:
City:
U.S. state/territory:
Zip code:
Country:
Int'l postal code:

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. Please be aware that Financial Aid cannot be assigned without a valid Social Security Number on file at this institution. Providing the Social Security number is voluntary.

NC Student Number:

Your NC Student Number (formerly NC Wise ID) is your North Carolina public high school identifier number and is only applicable to North Carolina High School students. Providing the NC Student Number is required for participation in Career & College promise, and will give you the opportunity to request your high school transcript electronically. If you are a public school student and do not know your number, you will find it on your most recent report card or you may obtain your IF from your high school counselor. If you are a private school or home school student residing in the State of NC and you do not have a NC Student Number, you may obtain a Unique Identifier (UID) by contracting systems_accounting@dpi.nc.gov.

Private school and home school students who have attended a k-12 public school in North Carolina may have an NC Student Number already. If you have a transcript or report card from the last public school you attended, you will find the number located there, or you may telephone the school to obtain your ID number. If the school was last attended prior to the school's NC Student Number implementation, please use the link in the paragraph above to obtain a Unique Identifier (UID).

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 Residency 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

Residency Information

RCN Number: *

Are you a North Carolina resident?*

If yes, select your county of residence:

Have you lived in North Carolina continuously for the past twelve months?*

If no, which state or country have you lived in for the past twelve months?

U.S. state/territory:

Country:

I have lived in North Carolina since:

mm/dd/yyyy

Military Service

Have you served in the U.S. Armed Forces?*
If yes, what type?
Are you eligible for VA education benefits?
Are you active duty military or a military dependent?*
If active duty military:
Where is your duty station?
Where is your home of record?
Branch of service:
If military dependent:
What is the expiration date of your military ID card?	mm/dd/yyyy
Where is your sponsor's duty station?

* = Required

Financial Aid

Do you plan to apply for financial aid?

* = 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:*
Are you a returning student?

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:
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:*

Have you received a High School Equivalency Diploma or Adult High School Diploma?*

AHSD (Adult High school Diploma) - Adults who did not complete their high school education but earned a high school diploma from a secondary school. An adult may earn a North Carolina Adult High School Diploma by completing twenty (20) units and by passing the North Carolina Competency Test in mathematics and reading. (Offered to students who did not graduate from high school.)

High School Equivalency Diploma - Four content area assessments: Language Arts, Mathematics, Science, and Social Studies which allow a test taker to demonstrate that s/he has attained the academic knowledge and proficiency of a high school graduate.

Students who received a High School Equivalency Diploma or AHSD must complete the fields below:

School:

City:

County:

(NC residents only)

U.S. state/territory:

Country:

Date completed:

mm/yyyy

* = Required

Other Colleges Attended

College/University:
Street:
City:
U.S. state/territory:
Country:
Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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College/University:
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City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
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Dates attended:	to: mm/yyyy
College/University:
Street:
City:
U.S. state/territory:
Country:
Dates attended:	to: mm/yyyy