CLAREDON COLLEGE APPLICATION FOR ADMISSION
COMPLETE ALL ITEMS (Please type or print clearly using black or dark blue ink.) Mail to Claredon College Health Center P.O. Box 207 Vicksburg, MS 39180
Applicant Information:
1. Full legal name ______________________________________________________________________________________________
First Middle Last 2. Other Name(s) Used (if applicable): (Nickname or
Preferred Name _________________________________________________________________________________
______________________________________________________________________________________________
3. Home Address City State/Province Country Zip/Postal Code
4. Date of birth Month Day Year 5. Age 6. Gender Female Male write in option:_______________
____________________________________________________________________________________________________
7. State of Birth 8. Country of Citizenship If not a U.S. citizen, other, specify country Government Information ________________________ Country of birth: ______________________ US Permanent Resident visa; citizen of ____________________________ Other Visa Type _____________________________________________
Alien registration number ______________________________________________________________________________________________
Other Citizenship Visa Expiration Date
If you live in the United States but are not a U.S. citizen, how many years have you lived in the country?
_____________
9. Permanent mailing address______________________________________________________________________
_________________________________________________________________________________________________________________________
Number and street or PO Box Apt. City State Zip Code 10. Current address, if different from permanent address
______________________________________________________________________________________________
______________________________________________________________________________________________
Number and street or PO Box Apt. City State Zip Code
______________________________________________________________________________________________
Social Security Number (Optional) Email Address
10. Home Telephone Number (include country, city, and area codes) 11. Cellular or Message Telephone
________________________Home__________________________Cell ____________________________Fax
Number (include country, city, and area codes) 12. Fax Number (include country, city, and area codes)
Text messages may be sent at this number. Yes ____ No ____
______________________________________________________________________________________________
13. Emergency contact full name
_____________________________________________________________________________________Who should be contacted in case of an emergency? Relationship to you (check one): Parent Guardian Spouse Partner, etc... Other Emergency contact physical address
______________________________________________________________________________________________
Number and Street Apt. City State Zip Code
Emergency contact phone: HOME ____________________ CELL/MOBILE _______________________
14. Ethnicity and Race Information (optional). The information you provide will not be used in a discriminatory manner. Are you Hispanic or Latino Yes ____ No ____ (country of family’s origin: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race). Which of the following best describes your ethnicity? (select one or more of the following categories): _____ Asian (country of family’s origin: Far East, Southeast Asia, or the Indian Subcontinent, for example, China, India, Japan, Korea, Cambodia, Pakistan, the Philippine Islands, Thailand, and Vietnam) _____ Native Hawaiian or Other Pacific Islander _____ Black or African American _____ White American _____ Indian or _____ Alaska Native Tribal affiliation).
This college is an Equal Opportunity/Affirmative Action institution and is subject to certain reporting and affirmative action requirements. The information required on this page is requested only so that we may satisfy group statistics for federal, state, and institutional reports.
15. Are you at least 18 years of age? Yes ____ No ____ Do You Plan to Apply for Financial Aid? ____ Yes ____ No
16. Are you eligible for VA benefits? Yes ____ No ____
17. Criminal Background Self-Disclosure Other than traffic violations, have you ever been convicted of a criminal offense? Yes ____ No ____ What was the nature of the crime? ________________________________________________________ When did the conviction occur? ________________________________________________________ If Yes Misdemeanor or Felony ________________________________________________________
Note: Please do not answer \"yes\" or provide any information about convictions that have been erased, expunged, erased, pardoned, sealed, annulled, vacated, set aside, and/or otherwise eradicated by a court.
High School Graduate: Yes ____ No ____ If yes date of graduation (expected) (M/YR)____ / _______
G.E.D Yes ____ No ____ I plan to receive a G.E.D Yes ____ No ____
Check Applicable Program of Study ______ CNA ______ ASN
I certify that all answers made in this application are true and correct to the best of my knowledge and belief. I understand that providing false or incomplete answers could disqualify me from acceptance or terminate my enrollment
_________________________________________ (Signature).
Education History
Most Recent or Current Courses
(Please list name, semester/trimester, and credit hours/values for each course)
Trimester/semester 1 Trimester/semester 1 Trimester/semester 1
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________________ __________________________________ __________________________________
___________________________________ __________________________________ __________________________________
List all high schools, colleges/universities (including summers), and academic programs you have attended. You must submit transcripts from each school.
High School Name Dates attended Location
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
College/University Name Dates attended Location
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________
___________________________ __________________________ __________________________