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Fields in
BOLD
are required fields.
Please fill out the form with as much information as possible.
The more accurate information we have, the faster your application records
will be complete.
_________________________________________________________________________________________________
Last Name:
First Name:
Middle
Name:
Maiden
Name:
Social
Security Number (no dashes please):
Note: The
information concerning race and religion is needed for statistical purposes
only.
Please refer to our disclosure below.
What is your ethnicity?
Race:
Date of Birth:
Sex:
Female
Male
Marital Status:
Single
Married
Divorced
Legal
Physical Address:
City, State,
Zip: City:
State:
Zip:
County:
Country of Citizenship:
Country:
US
Other:
If your mailing address
is different than your legal physical address, please provide the address in
the
mailing address fields below.
Mailing Street Address:
City
State
Zip
Home
Phone:
Cell Phone:
___________________________________________________________________________________________________________________________________________________________
Choose a method of communication. We prefer to
communicate with you via your personal email account,
but if you do not have
one, we can mail communications to your home address. Keep in
mind that once
you receive your EC email account information, we will use that instead of
your personal email account.
Send
communication to my personal email account.
My personal
email account is:
Send
communication to my home mailing address.
__________________________________________________________________________________________________________________________________________________________
High School: (Please send
high school transcript)
High School State:
Graduation
(Month, Year)
If not high
school graduate, when did you complete the GED (Month, Year) - send copy of
scores
GED completion
date:
Did you take the GED in
Mississippi?
YES
No
If GED was not taken in
MS, what state?
Have you taken
the ACT?
Yes
No
Did you send a
copy of the ACT to ECCC?
Yes
No (If "No" please send copy)
Have you ever
attended ECCC?
Yes
No
If Yes,
when?
Name on your
record when attended ECCC:
Parent,
Spouse, or Guardian:
Home Address:
Parent
Country of Citizenship
Have you ever
attended another college (send transcript from each college)?
Yes
No
If "Yes," what
college(s) did you attend?
_________________________________________________________________________________________________
What semester
do you plan to attend ECCC?
Fall
Spring
Summer
Year:
Program of
Study Desired:
_________________________________________________________________________________________________
IMPORTANT!
Electronic Signature below is required...
In lieu of a signature, your initials and date of birth are required for
verification of your application
for admission.
By entering your first and last initials, and the month, day, and year of
your birth, you are
affirming that the information provided in your
application to East Central Community College
is true and correct.
First Name Initial:
Last Name Initial:
Birth Month (2 digits, e.g. 05, 11, etc.)
Birth Year (4 digits, e.g. 1984, etc.)
East Central Community College is accredited by the
Commission on
Colleges of the Southern Association of Colleges and Schools
(1866
Southern Lane, Decatur, Georgia 30033-4097: Telephone number
404-
679-4501) to award the Associate Degree.
_______________________________________________
East Central Community College does not discriminate on the
basis of
race, color, religion, national origin, sex, age, or
handicap. The College
is in compliance with the Title VI of the 1964 Civil Rights
Act, Title IX of the
1972 Educational Amendments, Section 504 of the
Rehabilitation Act of
1973, and the Americans with Disabilities Act of 1990.
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