Jefferson Davis Community College fully complies with the Family Educational Rights & Privacy Act of 1974, a federal law designed to limit the disclosure of personally identifiable information contained in education records. Except for directory information as defined in the current college catalog, the personal information that you provide on this application for admission will not be disclosed to a third party without your express, written consent. If you would like to request non-release of directory information, please contact the Registrar.
-Personal Information
NAME:
First Name:
Middle Name:
Last Name:
SOCIAL SECURITY NUMBER Your social security number will NOT be used as your Student ID number. Enter with no dashes. ex:123456789
DATE OF BIRTH (mm/dd/yyyy):
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HOME ADDRESS:
Street or P.O. Box Number:
City:
County:
State:
ZIP Code:
HOME TELEPHONE NUMBER:
WORK PHONE:
EMPLOYER NAME:
EMPLOYER PHONE:
PERSON TO NOTIFY IN CASE OF EMERGENCY:
EMERGENCY CONTACT PHONE NUMBER:
PERMANENT ADDRESS (If different from mailing address):
Street or P.O. Box Number:
City:
County:
State:
ZIP Code:
EMAIL ADDRESS:
STATE OF RESIDENCY:
CITIZENSHIP:
U.S. Citizen
Resident Alien
Foreign Visa (Type of Visa: )
Country of Citizenship if not U.S.:
-Entrance Information
Please select the term for which you are seeking admission:
Year:
APPLYING FOR:
First-Time Admission
Readmission
If applying for readmission, please list all names under which you may have possibly been enrolled:
Name under which you were formerly enrolled (If same as present, write "same")
Campus Attended:
Dates of Attendance:
CAMPUS YOU PLAN TO ATTEND:
Brewton Atmore I plan to attend both campuses
MAJOR OR PROGRAM OF STUDY YOU WISH TO PURSUE:
PLEASE CHECK ALL THAT APPLY:
New college freshman Transfer from another college Workforce Investment Act referral Single Parent Dual Enrollment (attending JDCC while in high school) College Graduate Displaced Homemaker First Generation college student Former JDCC student Transient (Attending JDCC while degree-seeking at another institution)
-Academic information
HIGH SCHOOL FROM WHICH YOU GRADUATED (OR WILL GRADUATE):
Name of School
Location (City/State)
Year Graduated or Last Year Attended
TYPE OF HIGHSCHOOL DIPLOMA RECEIVED:
High School Diploma (Standard/Regular) High School Diploma (Advanced/Honors) Occupational Diploma** Certificate of Attendance** *Students who earned the Certificate of Attendance are not eligible for degree-credible programs/courses.
**Students who earned an Occupational Diploma must have also earned an ACT composite score of 16 or higher to be eligible for degree-credible programs/courses.
If you have not earned a high school diploma, have you earned a GED (or will earn)?
Yes No Not Applicable
If yes, where and when did you earn your GED?
State: Year:
MY EDUCATIONAL GOAL AT JEFFERSON DAVIS COMMUNITY COLLEGE IS (check all that apply):
Earn a degree (AA or AS) and transfer to another college Complete courses for transfer without earning a degree Take courses for personal interest and self-enrichment Take courses as a transient student (attend JDCC while degree seeking at another institution) Earn an AAS degree for immediate entry into a career Earn a certificate for immediate entry into a career Update skills for a job I presently hold Other (Please Specify):
Have you ever attended another college?
Yes No
If yes, please list all colleges previously attended in the space below. Official transcripts from each college must be mailed directly to the Registrar's Office at Post Office Box 958, Brewton, AL 36427. If you have not attended another college, you must request your official high school transcript or GED transcript to be mailed.
COLLEGES ATTENDED (List All):
COLLEGE (Begin with Most Recent)
LOCATION (City and State)
DATES OF ATTENDANCE
DEGREE (If Applicable)
ARE YOU ON SUSPENSION?
Students on suspension from another college must appeal for admission to the Admissions/Academic Standards Committee..
-U.S. Military Selective Service Act Compliance
All males between eighteen (18) and twenty-six (26) years of age must certify compliance or intent to comply with the United States Selective Service Act and State of Alabama Legislative Act 91-584 by checking one of the following:
I have registered with the Selective Service. I am not yet 18 and will register when I reach the age of 18. I am a veteran of U.S. Military service. I am not required to register.
- Federal / State Reporting Requirements
The following information is for federal/state reporting requirements and will not affect the admission decision in any way.
(For Reporting Purposes Only)
GENDER
Male Female
ETHNICITY
Hispanic or Latino Not Hispanic or Latino
RACE:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
-Statement of Application Agreement
I certify that if I am granted conditional admission to the College, I will submit all required admissions records to the Registrar
prior to the issuance of first semester grades. Otherwise, my continued enrollment will be denied pending receipt of all admissions records. I further certify that I have read and understand
the College's admissions policies in the current JDCC Catalog.
I understand that if a third party agency (state, federal, or private) that is funding my scholarship has not paid the College by the end of the registration period or by a thirty (30)
calendar day extension, I will be responsible for my payment of tuition and fees immediately. I further understand that if payment is not rendered immediately, the College may administratively
withdraw me from classes for which I have registered.
I further hereby state that all information contained herein is true and accurate to the best of my knowledge and I understand that any falsification of said information may subject me to dismissal from the College or to such other disciplinary action as may be appropriate to or called for by existing federal, state, and/or local statutes or by the college officials acting in accordance with published institutional rules and guidelines.
Yes No
-Statement of Non-Discrimination Policy
It is the official policy of the Alabama State Department of Postsecondary Education and Jefferson Davis Community College that no person in Alabama shall, on the grounds of race, color, disability, sex, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment. Title IX Coordinator (251) 809-1592.
