Application for Admission

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1 Admissions Office 800 U.S. Highway 29 N. Athens, GA Fax Elbert County Campus 1317 Athens Highway Elberton, GA Fax Greene County Campus 1051 Athens Tech Drive Greensboro, GA Fax Walton County Campus 212 Bryant Road Monroe, GA Fax Application for Admission The following items must be received by the deadline to complete the application. Incomplete applications will NOT be processed. COMPLETED and SUBMITTED Application for Admission Non-refundable, one-time $25.00 application fee Official transcripts from high school, GED and /or college* Entrance test scores (ASSET, SAT, ACT or COMPASS)* Proof of residency and legal presence in the United States (state issued ID, passport, etc.) Copy of resident alien card (if applicable) *Official transcripts, entrance test scores, proof of legal presence and resident alien cards may be submitted at a different time but must be received by the ATC Admissions Office on or before the application deadline for each semester. APPLICATION DEADLINES ARE FALL SEMESTER- JULY 1, SPRING SEMESTER- NOVEMBER 1, SUMMER SEMESTER- APRIL 1. Applications submitted after the deadline will be subject to a $20 late processing fee in addition to the $25 application fee. Students registering during late registration and drop/add will also be subject to a $45 late registration fee SECTION 1 - Personal Information Choose the campus you plan to attend: Athens Elbert Walton Greene Not Sure Social Security Number: (xxx-xx-xxxx) Name: (Last, First, MI) Previous Name(s): (if applicable) Date of birth: (MM-DD-YYYY) Address: 1

GA 30642 706-453-7435 Fax 706-453-2583 Walton County Campus 212 Bryant Road Monroe, GA 30655 770-207-4080 Fax 770-207-4071 Application for Admission The following items must be received by the

2 Apartment or Lot #: City : State: Zip Code: County of Residence: Country: Address: Day Phone: Evening Phone: Emergency Contact: Emergency Contact Phone: SECTION 2 Statistical Data This information is required for purposes of reporting to federal compliance agencies and will not be used in determining admissions status 2A: Gender: Male Female Are you Hispanic/Latino? Yes No Please select one or more races from the following racial groups: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 2B: Are you a military veteran? Yes No Are you active military? Yes No Are you a military Dependent or Spouse? Yes No If you answered Yes to any question regarding military service, which branch applies to you? Air Force Army Coast Guard Marine Navy National Guard Reservist Did your Father attend college? Yes No Unknown Did your Mother attend college? Yes No Unknown 2

Yes No Please select one or more races from the following racial groups: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 2B: Are you

3 SECTION 3 Residency Information 3A: Are you a U. S. Citizen? Yes No (If YES, you may skip to part 3B) If NO, are you a Permanent Resident? Yes No If you are a Permanent Resident, please provide a copy of your Permanent Resident Alien Card. If you are NOT a Permanent Resident, are you an International Student? Yes No If you are not a U.S. Citizen, what is your country of citizenship? What is your current VISA status? Do you need an F or M Student Visa? 3B: Have you lived in Georgia at least 12 consecutive months? Yes No Which of the following applies to you: I am UNDER 24 years of age, my parent(s) or legal guardian(s) have claimed me on their most recent federal/state tax return, and they HAVE resided in the state of GEORGIA for the last 12 consecutive months. I am UNDER 24 years of age, my parent(s) or legal guardian(s) have claimed me on their most recent federal/state tax return, and they HAVE NOT resided in the state of GEORGIA for the last 12 consecutive months. I am over 24 years of age (or under 24 and neither parent or a legal guardian claimed me on their tax returns) and HAVE lived in Georgia for the last 12 consecutive months. I am over 24 years of age (or under 24 and neither parent or a legal guardian claimed me on their tax returns) and HAVE NOT lived in Georgia for the last 12 consecutive months. SECTION 4 - Application and Program Information Term you plan to enter school: Summer (May) Fall (August) Spring (January) Year you plan to enter school: Have you ever been accepted or enrolled at? Yes No If yes, what term and year? Applying as what type of student: Beginning Returning Transfer Transient Dual Enrollment/ACCEL Special Admit** PROGRAM OF STUDY: Health Information Technician Certificate 3

udent? Yes No If you are not a U.S. Citizen, what is your country of citizenship? What is your current VISA status? Do you need an F or M Student Visa?

4 EDUCATIONAL AND TEST DATA Indicate any of the following tests taken within the last 5 years: SAT ACT ASSET Compass None Taken HIGH SCHOOL INFORMATION High School Attended: City/State GRADUATION INFORMATION Please fill in the following. Note: High school special education diplomas and certificates of attendance are not accepted. All required exit exams must be passed. You must submit an official copy of your high school transcripts or your GED test scores to the Admissions Office if you have earned fewer than 45 quarter hours or 30 semester hours in college. High school graduation date: Anticipated high school graduation date: GED Certificate date : Have not earned high school diploma or GED Highest grade level completed beyond high school: Some college- no degree earned Associates Bachelors Masters Doctorate COLLEGE INFORMATION Please list ALL postsecondary institutions (including Athens Tech) you have attended. Any student who does not list each previous institution attended may be subject to dismissal without refund. (List last institution first). You must request official transcripts from ALL institutions attended and they must be mailed by the releasing institution or hand delivered in an unopened envelope (sealed by the releasing institution) to the Admissions Office at Athens Tech. 4

You must submit an official copy of your high school transcripts or your GED test scores to the Admissions Office if you have earned fewer than 45 quarter hours or 30 semester hours in college.

5 Application for Admission - Signature Page By submitting this application, I give permission to contact me at the telephone numbers I have provided via any means, including text message or voice. I certify that the foregoing information contained in this application is true and correct. I understand that misrepresentation or omission of information will be sufficient cause for rejection or dismissal. Print Name : (Last Name, First Name M.I.) Signature : Date : As set forth in its student catalog, does not discriminate on the basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law). The following individuals have been designated to coordinate the colleges implementation of nondiscrimination policies: Keli Fewox, Director of Student Support, Section 504 and the Americans with Disabilities Act (ADA) Coordinator, Office H-748, 706/ , kfewox@athenstech.edu, Becky Burton, Director of Human Resources, Title VI, Title VII, and Title IX Coordinator (Employees), Office J-211B, 706/ , bburton@athenstech.edu, and Dr. Leslie Crickenberger, Vice President of Student Affairs, Title IX Coordinator (Students), Office H-774, 706/ , lcrickenberger@athenstech.edu, 800 U.S. Highway 29 North, Athens, GA

I understand that misrepresentation or omission of information will be sufficient cause for rejection or dismissal. Print Name : (Last Name, First Name M.I.) Signature : Date : As set forth in its

College Credit Now ADMISSION APPLICATION ACCEL DUAL ENROLLMENT JOINT ENROLLMENT MOVE ON WHEN READY. www.chattahoocheetech.edu

College Credit Now ADMISSION APPLICATION ACCEL DUAL ENROLLMENT JOINT ENROLLMENT MOVE ON WHEN READY. www.chattahoocheetech.edu College Credit Now ACCEL DUAL ENROLLMENT JOINT ENROLLMENT MOVE ON WHEN READY ADMISSION APPLICATION www.chattahoocheetech.edu RELEASE OF INFORMATION CONSENT ACTION FORM FOR COLLEGE CREDIT NOW Student Name