Enrolling for (select one): Select Term Fall Spring Summer   Year:

Enrollment Status (select one): Select Status First Year(0-29 hours) Second Year (30-64 hours) College Graduate Other

For which of the following reasons are you interested in seeking higher education:
Select Reason Complete coursework toward degree or certificate completion at two-year institution Complete coursework toward degree at transfer institution Obtain or improve job skills Acquire or maintain licensure Improve self/personal enrichment (non-job related skills) Complete coursework for concurrent credit Complete tech prep coursework Explore educational opportunities Other Unknown

EMERGENCY CONTACT INFORMATION

Name:   Relationship:

Telephone:   Address: 

EDUCATIONAL INFORMATION

High School you attended/attend:   Date of Graduation:

If you have not graduated, do you hold a GED  Yes No

Date Received:    State that issued GED:

List all colleges or universities at which you have taken courses for credit.  In order to receive credit, you must provide a transcript to the Student Affairs office.

Name of College, Location (City, State), Degree and/or Credit Hours, Dates Attended:

 

The following information will be used for reporting purposes only. Sex: Select Sex M F   Birth Date:   Place of Birth: Ethnic Origin: Select Ethnic Origin American Indian or Alaskan Native Asian or Pacific Islander Black Hispanic White Other Have either of your parents graduated from college? Both Select a Choice Father Mother None

The University of Arkansas Community Colleges, in accordance with Arkansas law, require entering students to provide proof of immunization of both measles and rubella or proof of exemption from this requirement.

Selective Service Declaration

All people seeking admission to The University of Arkansas Community Colleges must complete this form in accordance with ACT 228 of 1997.

Sworn under penalty of perjury, I certify that I am:

Registered with the selective service of the United States of America: No Yes

Not registered with the selective service because I am:
Select Reason under 18 years of age in the armed forces of the United States on active duty, other than in a reserve or national guard unit currently an alien unlawfully admitted to the United States as a non-immigrant. a permanent resident of a trust territory of either the Pacific Islands or the Northern Mariana Islands excused from registration for another reason by federal law

I hereby certify that all information is complete and accurate.  By submitting this form, I understand that I will not be considered for admission to the University of Arkansas Community Colleges until I have submitted all documentation specified for admission and enrollment.  Upon registration, student agrees that voice, physical presence, and participation in virtual classroom activities may be transmitted to distance sites and electronically recorded.