APPLICATION FOR ADMISSION
For Office Use Only
Application Date: ____________
Application Status: ___________
Application Status: ___________
Processed By: _______________
Instructions:
Complete this form in ink and print clearly. Submitting an incomplete or unsigned application will delay the admission
process. Completion of the application process requires submission of an Official Transcript from each postsecondary
institution attended. If you have never attended college an Official High School Transcript or equivalent is required (If you
graduated from a Louisiana public high school after May 2003 the college will obtain your official transcript).
STUDENT INFORMATION
Student SSN:
Date of Birth:
Last Name:
First Name:
MI:
Maiden Name:
Address:
City:
State:
Zip Code:
Home Telephone:
Cell Telephone:
Email:
Gender:  Female  Male
Race/Ethnicity: (Optional)
 African American
 American Indian/Alaskan Native
 Asian
 Caucasian
 Hispanic
 Native Hawaiian/Other Pacific Islander
 Other ________________________________________
CITIZENSHIP
U.S. Citizen  Yes  No
If non-U.S. Citizen: Current Visa or Current Status: ________________________________________
Country of Citizenship _______________________________________________________________
Resident Alien Number ______________________________________________________________
EMERGENCY CONTACT
Emergency Contact Name and Relationship:
Emergency Contact Telephone:
RESIDENCY INFORMATION
Eligibility for classification as a resident of Louisiana is determined by the Enrollment Services in accordance with BRCC
regulations and is based on evidence provided in the Application for Admission and other related documents. Requirements for
residency are determined by the location of the home and place of employment. A resident student is a student who has lived and
worked in Louisiana for at least one full year (365 days) immediately preceding the first day of class of the term for which
classification as a resident is sought. Residence cannot be established for the sole purpose of obtaining an education. Resident
classification and all fees are audited after registration and are adjusted as necessary. Documentation used for verification of
residency includes a current driver’s license, a voter registration card, and/or copies of state tax records.
How long have you lived in Louisiana? ________ Years __________ Months
Documentation utilized to verify current residency (only one required).
 Louisiana Driver’s License # _____________________________ Date of Issue ______________________
 Louisiana Voter’s Registration # __________________________
 Louisiana Income Tax Return showing state taxes paid _______________________________
 Other ______________________________________________________________________
Baton Rouge Community College is an Equal Opportunity/Equal Access Employer
EDUCATIONAL BACKGROUND
High School Information
High School Diploma Received
 Yes  No
Year ________GPA ______
Name of School _____________________________
Are you a first generation college student in your
family?  Yes  No
GED Information
General Equivalency Diploma
(GED)
Dual Enrollment Information
Are you currently a HS Student?
 Yes  No
 Yes  No
If yes, will you receive HS credit
for courses taken?  Yes  No
If yes, Year _____________
Did you participate as a Tech
Prep student in articulated credit?
 Yes  NO
List LCTCS Campuses and/or College Attended
Name of Institution
City, State
Dates Attended
From: Mo/Yr
To: Mo/Yr
Degree/Diploma/Certificates
ADMISSION INFORMATION
Term of Application : Fall ____________
Admission Status:
Campus:
Program Major:
Choose from campus program offerings
Degree Type:
Please check appropriate box:
Spring _____________ Summer ____________
 Frist Time  Returning  Transfer
 Degree seeking – I intend to complete a certificate, diploma, or
associate degree program
 Non-degree – I am interested in selected courses only and do not
intend to complete the entire program
 CDA certification preparatory courses
SELECTIVE SERVICE (Complete the Lettered Item that describe your registration)
A.  I certify that I am not required to be registered with Selective Service because: (check one)
 I am Female
 I am in the armed services on active duty (Note: Members of the Reserves and National Guard are not considered on
active duty)
 I am not 18 years old
 I was born before 1960
 I am a permanent resident of the Trust Territory of the Pacific Islands or the Northern Mariana Islands
 I am a Veteran
B.  I certify that I am registered with the Selective Service.
Selective Service Number: ______________________________________
Privileged Information Release
I hereby authorize this school’s officials or instructors to release information concerning my school records to my parent or
guardian, present or former high school, schools to which I may transfer, agencies from which I am receiving financial aid,
prospective employers, or other official inquiries. I understand in executing this authorization I waive the right for such
information to be privileged and that a photocopy of this authorization shall be as valid as the original.
 Yes  No
Student Signature: ___________________________________________
Date: ____________________________
Baton Rouge Community College is an Equal Opportunity/Equal Access Employer
AUTHORIZATION
High School Transcript Release & Statement of Information Accuracy
I do hereby authorize Louisiana public postsecondary education access to my academic records and certify that all of the
information provided on this form is true and correct.
Applicant’s Signature: ___________________________________ Date: _____________________
FOR OFFICE USE ONLY
Placement Scores:
ACT
ASSET
COMPASS
Test Date
Reading
_____________
_____________
_____________
_____/_____/______
Mathematics
_____________
_____________
_____________
_____/_____/______
English/Writing
_____________
_____________
_____________
_____/_____/______
Baton Rouge Community College (BRCC) is accredited by the Commission on Colleges of the Southern Association of Colleges and Schools
(1866 Southern Lane, Decatur, Georgia 30033-4079; Telephone number 404.679.4501) to award Associate Degrees and Certificates. Educational
opportunities are offered by the Baton Rouge Community College without regard to race, color, age, national origin, religion, gender, or disability.
The Director of Disability Services has been designated as the college’s 504/ADA Compliance Officer. Any person with a disability who needs
assistance should contact the Director at 225.216.8503, TDD 225.216.8702. Baton Rouge Community College does not discriminate on the basis
of gender in admission to or employment in its education programs or activities. Title IX Coordinator is the Vice Chancellor for Student Affairs,
5310 Florida Boulevard, Baton Rouge, Louisiana 70806 – 225.216.8068. The Family Educational Rights and Privacy Act of 1974, as amended
(also sometimes referred to as the Buckley Amendment), is a federal law regarding the privacy of student records and the obligations of the
institution, primarily in the areas of release of the records and the access provided to these records. Any educational institution that receives funds
under any program administered by the U.S. Secretary of Education is bound by FERPA requirements. Institutions that fail to comply with
FERPA may have funds administered by the Secretary of Education withheld.
BRCC is a member of the Louisiana Community and Technical College System (LCTCS).
Baton Rouge Community College is an Equal Opportunity/Equal Access Employer