Halifax Community College-SSS-Application Form

STUDENT INFORMATION

Name*

First NameMiddle NameLast Name

Student ID

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number

(999)999-9999

Home Phone Number

(999)999-9999

Birth Date

mm-dd-yyyy

Age

Gender

MF

Email Address*

example@example.com

Citizenship

United States CitizenPermanent ResidentOther

Ethnic Background

Do you have a disability?

YesNo

Did your MOTHER graduate from college with a 4-year degree?

YesNo

Did your FATHER graduate from college with a 4-year degree?

YesNo

Are you receiving financial aid?

YesNo

If yes, are you considered an

Independent StudentDependent StudentDon't Know

If No, check the reason(s):

Have not appliedWas not eligibleOther

Current Classification

Incoming FreshmanFreshmanSophomore

Returning Student Current Course Load

Full-time StudentPart-time StudentLess than Part-time

When was your first semester at Halifax Community College?

(Month,Year)

Number of course hours completed at HCC so far:

Cumulative GPA

What are your academic plans?

CertificateDiplomaAssociate DegreeTransfer Credit Only

What is your career goal?

If undecided, write Undecided

Are you planning to transfer to a four year school after graduating from Halifax Community College?

YesNo

Are you planning to transfer prior to receiving a degree/certificate from Halifax Community College?

YesNo

Referral Source

If you need tutoring assistance, please indicate the subjects/courses:

I certify that all the information on this form is true and complete to the best of my knowledge. I also authorize the HCC SSS Project permission to obtain and review any academic and financial documents needed to complete the application process.

Signature

Date Signed

mm-dd-yyyy