Application for Admissions
Enrolling for
*
Summer
Year
*
Please Select
2024
Which Phillips College campus do you plan to attend?
*
Please Select
DeWitt
Helena
Stuttgart
Online Only
Social Security Number
*
First Name
*
MI
*
Last Name
*
Street Address
*
City
*
County
*
State
*
Zip Code
*
Email Address
*
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Place of Birth
*
How long have you lived in Arkansas? Years/Months
*
How long have you lived in Phillips or Arkansas County? Years/Months
*
Race-Ethnicity
*
Please Select
Asian
Hawaiian/Pacific Islander
Hispanic
American Indian/Alaska Native
Black or African-American
White
International Students: If you are not a citizen of the United States, what is your country of citizenship?
Visa Type
Sex
*
Male
Female
Have you previously attended PCCUA?
*
Yes
No
If yes, please indicate the name under which you last attended
Name of High School Attended
*
(If current high school student, list grade level)
High School Graduation Date
-
Month
-
Day
Year
Date
If you are not a high school graduate and have passed the G.E.D or hold an equivalency diploma, indicate date completed
-
Month
-
Day
Year
Date
State issued G.E.D.
Choose highest education level completed by Mother
*
Please Select
Did not complete high school
High School
Some college
2-year college degree
4-year college degree
Choose highest education level completed by Father
*
Please Select
Did not complete high school
High School
Some college
2-year college degree
4-year college degree
List all the colleges & Universities previously attended in order of attendance, including any attendance of PCCUA. Date attended / Institution / State. (Enter none, if none attended)
*
What will be your Program of Study while at PCCUA?
*
Name and address of parent or legal guardian, if
under 21 years of age
First Name
Last Name
Street Address
City
State
Zip Code
Are you a single parent?
*
Yes
No
Are you unemployed or not making enough to support yourself or your family?
*
Yes
No
Is English your primary language?
*
Yes
No
Have you ever plead guilty to, nolo contendre to, or been convicted of a felony?
*
Yes
No
If yes, explain
Signature
*
View the Higher Education Consumer Guide
here
.
Date of Application
*
-
Month
-
Day
Year
Date
By checking the box below, I hereby make my application for admission to PCCUA and agree to abide by the regulations of the college while I am a student. I furthermore declare that the information on this application is complete and accurate. Any collection cost incurred as a result of an overdue balance will be passed on to the student.
I agree
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