ACCELERATED RECOMMENDATION FORM

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1 ACCELERATED RECOMMENDATION FORM Admissions Office 1900 U S Highway 31 South Bay Minette, Alabama (251) or (800) ext Student s Name Social Security Number: - - High School Grade Level Cumulative Grade Point Average Term of Enrollment The student whose name appears above has met the enrollment criteria for Accelerated High School Students, including completion of 10th grade, a minimum cumulative 3.0 GPA, and is hereby recommended to enroll in any postsecondary courses at Faulkner State Community College for which prerequisites are met. Principal or Principal Designee Title Release of Academic Record I authorize Faulkner State Community College to release my academic record on a semester basis to my high school. This release shall remain in effect until I provide written notice to the Records Office to discontinue the release or until I earn my high school diploma. Student Signature It is the official policy of the Alabama State Department of Education, including Postsecondary institutions under the control of the State Board of Education, that no person in Alabama shall, on the grounds of race, color, disability, sex, religion, 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.

2 Application for Admission FAULKNER STATE COMMUNITY COLLEGE OFFICE OF ADMISSIONS 1900 HWY 31 SOUTH BAY MINETTE, ALABAMA OR

3 Faulkner State Community College 1900 Highway 31 South, Bay Minette Alabama (251) Application for Admission Complete this application for admission in blue or black ink. Please print clearly. Be sure to complete all sections and sign the last page before returning to the Admissions Office at the above address. Social Security Number Application Month Day Year Entry Status (check one) First time college student Transfer student Transient student Dual enrollment high school student Accelerated high school student Early College Enrollment Program (ECEP) Audit only Senior citizen Full Name Last First Middle Preferred name: Other names under which transcripts might be listed: Current Mailing Address County of Residence Street or P.O. Box Apartment Number City State Zip Address Home Phone No. (including area code) Cell Phone No. (including area code) Gender Male Female Status Single Married Divorced Widowed Ethnic Origin Nonresident alien Race & ethnicity unknown Hispanics of any ethnicity Asian American Indian/Alaskan Native Black/African American Native Hawaiian or Pacific Islander White Two or more races Program of Study Award Option Associate Degree Certificate (one year) Training Certificate Non-degree seeking Purpose for attending FSCC Graduate and transfer Transfer to another college Graduate & enter workforce Transient student Personal enrichment Improve job skills High school / honors program Enrollment Term Fall Spring Summer Year of Birth Place of birth Month Day Year City State County Emergency Contact Name Telephone No. (including area code) Relationship Current Address

4 High School Education High school diploma High school certificate AL occupational diploma Earned GED Year: High school: City/State: No diploma or GED Last grade completed: Do you have an Alabama Career Readiness Certificate? No List all universities, colleges, and postsecondary community, junior & technical colleges previously attended. You must report all institutions attended and request official transcripts from each. Name of College City/State Did you graduate? Award Earned Attendance s On Academic Suspension or Probation from this college? Citizenship Are you a citizen of the United States? No Country: Also, enclose a photocopy (front & back) of your resident alien card. Residency Are you a legal resident of the State of Alabama? No State: Current Employment Information Provide CURRENT status and employer information only. Current employer s name: Employment Status Full time Part-time Unemployed Employed in a field related to your program of study? No Not applicable Address: City/State/Zip: Phone No., including area code: Occupation/position: The information you supply in this section of the admission application is strictly voluntary and will be kept completely confidential. The responses you provide will be used for research purposes and will not be individually listed on any report. If, however, any question requests information that you do not wish to provide, please omit it. Special Populations Status (check all that apply) 1. Is English your second language? No 2. Are you a single parent or a single pregnant woman? No 3. Displaced Homemaker a. Did you work primarily without pay to care for a home and family? No OR Were you dependent on an income from another family member who No is no longer providing that support? b. Is your youngest dependent child age 16 or older? No AND Does he/she receive Family Assistance Program benefits? No c. Are you unemployed or underemployed and experiencing difficulty in No obtaining or upgrading employment? 4. Did your mother and/or father or primary caregiver graduate from a No four-year college? Do you have Internet access in your home? No How did you hear about Faulkner State? Radio commercial TV commercial Direct mail insert Website Billboard Phone book Friend/family member Employer Information mailed to you High school counselor Campus visit Agency (rehab, WIA, etc.) Technical career expo ACT Visit to your high school/career tech center by College personnel

5 CERTIFICATION FORM In-State and Out-of-State Residency Student Name: SSN: Current Address: City: County: State: Zip: RESIDENCY STATEMENT Please read the following statements and check the ONE statement that applies to you and sign the bottom of the page. I have lived in the state of Alabama for at least the past 12 months. I certify that the address above is my residence and I intend to remain at this address indefinitely. Students cannot attain resident student status simply by attending school for twelve months in the state of Alabama. I am a minor, and my parents/legal guardian(s) have lived in the state of Alabama for at least 12 months. I currently live in one of the following counties of Florida that is within the 50-mile radius of the campus that I wish to attend. I certify that the address and county listed above is my residence and I intend to remain at this address indefinitely. Escambia Santa Rosa I do not currently live in the state of Alabama and I am considered an Out-of-State student. I certify that I do not meet any requirements to be classified as an in-state student. An out-of-state student cannot attain resident student status simply by attending school for twelve months in the state of Alabama. I have currently lived in the state of Alabama for less than 12 months. However, I certify that I possess more substantial connections with the state of Alabama than any other state at the time of this application. I further certify that the address above is my residence and I intend to stay at this address indefinitely. You may be required to provide sufficient documentation to the Director of Admissions. The Director of Admissions must certify all documentation before the in-state tuition rate is official. I certify that I have read the statements above, and I have selected the statement that best meets my qualifications. Signature of Student I understand that withholding required information requested on this application or giving false information could make me ineligible for admission to or continuation at Faulkner State Community College. I agree to abide by the rules, policies, and regulations of the College as stated in the College Catalog. I attest that the information given is accurate and complete to the best of my knowledge. I understand that Faulkner State Community College owns all photographs of students and participants taken at Faulkner State events, and that Faulkner State reserves the right to use these photographs for College promotional materials, both digital and print. If I do not wish to have my photographs used, I understand that I must file a Do Not Use Photograph form with the Faulkner State College Relations Office. Applicant s Signature If under age 18, parent or legal guardian must sign here. Printed name: Parent / Legal Guardian s Signature Equal Opportunity in Education and Employment It is the official policy of the Alabama Department of Postsecondary Education and Faulkner State Community College that no person shall, on the grounds of race, color, disability, sex, religion, creed, national origin or age be excluded from participation in, denied the benefits of, or be subjected to discrimination under any program, activity, or employment.

Award Earned. Did you graduate? Yes

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