Signature Page
Thank you for applying to Jefferson State Community College.
Please sign and return this page to the Enrollment Services office at the campus most convenient to you. You may also mail it to the Admissions
Office, 2601 Carson Road, Birmingham, AL 35215 or fax to (205)856-8091.
Please make sure that all transcripts are sent directly to the Admissions Office, 2601 Carson Road, Birmingham, AL, 35215. If you have never attended college, you should
request that your official high school or GED transcript be sent to the college. If you have attended another college (s), you should request that your official college transcript
(s) be sent to the college. You may review the complete transcript requirements on our homepage from this link http://www.jeffstateonline.com/admissions/.
Failure to submit your transcripts will result in a registration hold on your record and you will not be allowed to register for the next term of attendance.
Also, if you are receiving financial aid, all in-house paperwork and transcripts, including non-accredited colleges, MUST be in the admissions office
before financial aid will be awarded.
All degree-seeking students who enroll for more than 4 credit hours must take and submit the Compass Placement Test or SAT/ACT scores.
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT – BUCKLEY AMENDMENT
NOTICE: Under the Federal Family Educational Rights and Privacy Act 20 U.S.C. 1232g Jefferson State Community College may disclose certain student information
as “directory information.” Directory information includes the names, addresses, telephone numbers, dates of birth and major fields of study, information about
participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, degrees and awards received, and the
most recent previous educational agency or institution attended. If any student objects to the aforementioned information being released the student should notify, in
writing, to Enrollment Services.
RESIDENCY INFORMATION: The following information must be completed. Please select the one that applies most to you.
I have lived in the State of Alabama for at least 12 months. I graduated from an Alabama high school and have no connections to
any other state.
I am a minor and my legal guardians have lived in Alabama for at least 12 months. I graduated from an Alabama high school and
have no connections to any other state.
I do not currently live in Alabama and I am considered an out–of-state resident. I understand I cannot attain resident status by
attending school for 12 months in Alabama and out-of–state tuition rates will apply.
I have lived in Alabama for less than 12 months. I certify that I possess more substantial connections with Alabama than any other
state. I agree to submit an application for in-state residency and attach required documentation.
I have lived in Alabama for more than 12 months. I have some out-of –state connections but I certify that I possess more connections
with Alabama. I agree to submit an application for in-state residency and attach required documentation.
I am an international student with an F-1 student visa. I understand that out-of-state tuition rates will apply.
Policies and Procedures
Students are responsible for knowing the policies, procedures, and deadlines outlined in the Jefferson State Class Schedule and the Jefferson State Catalog
& Student Handbook.
By signing this form, I acknowledge that I have met the admissions requirements and I certify that all information provided is accurate to the best of
my knowledge. I understand that falsification of information in this application could result in dismissal or other disciplinary action.
By signing, I voluntarily consent to receive information (including financial aid information) in electronic transactions, via Self Service
Banner and/or college email. (Please contact the Financial Aid Office if you wish to rescind this consent for electronic notification.)
Name (Print):____________________________________ Signature: _________________________________________
Date of Birth:___________________________________
Date____________________________________________
Jefferson State does not discriminate on the basis of race, color, national origin, sex, disability, or age in its admissions, programs and services in
compliance with Title VI and VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975,
and Title IX of the Educational Amendments of 1972, and the Americans with Disabilities Act of 1990.