N on -D egree S tudent
Admissions Application & Registration Form
Please Complete The Entire Application and Sign.
1. Social Security Number: ______ ______ ______ – ______ ______ – ______ ______ ______ ______
2. Name: _ ___________________________________ _ _______________________________________ ________________________________
Please list any other name you have used for work or school, including maiden name: ___________________________________________________
Last First Middle
3. Address: ______________________________________________________________ _______________________________________________________________
Street E-mail address
City ___________________________________________________ _____ _____ _____ _____ _____ _____ _____ – _____ _____ _____ _____
State ZIP code
4. County:_ _________________________________________
14. What year did you or do you expect to graduate _______ or
5. Day phone:(___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
15. List the high school you attended or are attending and its location: _ ___________________________________________
Evening phone:(___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
6. Gender (m/f):
_ _______
7. Birth date:
_ _______
8. U.S. citizen (y/n)
_ _______
9. Ethnic background: _ _______
1. White (non-Hispanic) 2.Black (non-Hispanic) 3.Hispanic
4. Asian/Pacific Islander 5.American Indian or Alaskan Native
10. Which campus will you be attending?
_ _______
1. Wheeling 2. Weirton 3. New Martinsville
11. How long have you lived at your current address? _ _______
If less than one year, please list all addresses used
in the past 12 months and the length of time at each:_______
­________________________________________________
__________
from ________________________ to _________________
__________________________________________________
_______
from ________________________ to__________________ 12. Are you a West Virginia resident (y/n)?
_ _______
13. Are you a resident of Belmont, Harrison, Jefferson, or
Monroe County in Ohio (y/n)? _ ______ R egister M e F or T he F ollowing.
­
CRN
Course Title
receive your GED _______?
16. Have you ever attended WVNCC (y/n)
_ _______
If yes, under what name_____________________________ _________________________________________________
17. Which best describes why you are taking this course?
1. Personal interest 2. Workplace skills 3. Student at another 4. High school student
college
18. In case of emergency, notify:
Name:_ __________________________________________
Relationship:_ _____________________________________
Phone:___________________________________________
I certify that all the information provided in this application is complete and
correct to the best of my knowledge. I understand that any false information
or omission of information relating to residency, citizenship and previous
college attendance is cause for suspension from West Virginia Northern
Community College. I will acquaint myself with and abide by the student
code of conduct, including compliance with the Drug-Free Schools and
Communities Act, and other requirements governing the academic and
social standards of West Virginia Northern Community College.
________________________________________________________
Signature
Date
Credits
Cost
Total
Payment Enclosed: Check $ ______________ (Please make payable to WVNCC.)
Credit Card-Circle One: Master Card, Visa, Discover, American Express
Number _____________________________________ Exp. Date _ __________________________________________
Signature ________________________________________________________________________________________
Rev. 8/04
_ ______ Signature required if paying by credit card.
Program Codes*
Workplace Skills Credentials
258S AAPC Medical Coding Credentialing Program
327S Child Care
271S Computer Office Applications
Other Interests
601
700
American Institute of Banking
Classes arranged for business and industry
302S Customer Service
311S Digital Print Technician
307S Entrepreneurial and e-Business Skills
900 Non-major
609 Paramedic+
605P Phlebotomy+
* Codes for additional programs will be provided by College staff.
+This area of study requires a separate application and service fee.
Return this application to:
New Martinsville
141 Main Street
New Martinsville, WV 26155-1211
304.455.4684
Weirton
150 Park Avenue
Weirton, WV 26062-3797
304.723.2210
Wheeling
1704 Market Street
Wheeling, WV 26003-3699
304.233.5900
www.wvnorthern.edu
info@northern.wvnet.edu