Application for Admissions

Enrolling for *

Summer Fall Spring

Year *

Which Phillips College campus do you plan to attend? *

Social Security Number *

First Name *

MI *

Last Name *

Street Address *

City *

County *

State *

Zip Code *

Email Address *

Phone Number *

Date of Birth *

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 *

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

Date

If you are not a high school graduate and have passed the G.E.D or hold an equivalency diploma, indicate date completed

Date

State issued G.E.D.

Choose highest education level completed by Mother *

Choose highest education level completed by Father *

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 *

Clear

Date of Application *

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