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Date:
ID:
____ PCSECHS
SEM/Year ________
To be eligible for enrollment, a high school student must meet the following criteria:
City
Home Telephone
Date of Birth
Ethnicity
State
Country of legal residence
Mobile Telephone
Sex
F
Yes
Zip
No
Asian
E-Mail Address
Spring
Enrolling as
White
I plan to attend
Summer
Full-time
Part-time
Freshman
Transfer
Curriculum Code
U.S. Citizen
GR
TR
Yes
Citizenship
No
US Citizen
Issue Date
Expiration Date
Issue Date
Expiration Date
Page 2
RESIDENCE
Are you a North Carolina resident?
Yes
No
If YES, what is your county of residence?
In what state do you pay State Income Tax?
Enter your drivers license number
In what state was your drivers license issued?
Have you lived in North Carolina continuously for the past 12 months?
If NO, where else have you lived in the past 12 months?
Are you Active Duty Military or a Military Dependent?
If you are active duty, where is your duty station?
If military dependent, where is your sponsors duty station?
Please select one of the two following statements. If the residence status of you or your parents is such that you cannot select either of the
statements, write a letter of explanation and attach it to this application. If in doubt of status, please contact the Vice President of Student
Development.
Resident: This is to certify that I have been a legal resident, or (if under 18) my parents have been legal residents of North Carolina for
the twelve months immediately preceding the date on which I will enroll at Pitt Community College.
Non-Resident: In applying for admission to Pitt Community College, I acknowledge my ineligibility for the resident tuition rate. (A
petition for reclassification may be filed at the end of the qualifying twelve month domicile period.)
Yes
Relationship
Phone
No
I hereby certify that the information I have given is true to the best of my knowledge. I further understand that falsification or failure to supply the correct
information may be considered grounds for rejections or dismissal.
Applicants signature
Date
Signature of parent/guardian
Date
if applicant is under 18