APPLICATION FOR ADMISSION Application Information and Instructions: APPLICATION: Complete the attached application form in detail and Melbourne Campus (321) 433-5650; Palm Bay Campus (321) 433-5172; forward it to the Admissions and Records Office at the campus you plan Titusville Campus (321) 433-5017. to attend. Any student omitting information or falsifying the application or records will be subject to immediate dismissal without a refund.Your LIMITEd ACCESS PROGRAMs: Admission to the college neither signature is required on page 4. Incomplete applications will be returned constitutes nor guarantees admission to limited access programs such as without processing. health sciences or criminal justice academies. If you plan to enter one of these programs you must request a separate application packet for the APPLICATION FEE: $30 U.S. Citizen/Permanent Resident, $60 International. specific program. You must submit that application and required fees and This is a non-refundable fee that must be submitted with the application. documents directly to the location designated for the program. REsIdency: All students must complete and sign the enclosed dEGREE/CERTIFICATE dEsCRIPTIONs residency affidavit and submit with supporting documentation. See program information in college catalog. INTERNATIONAL sTUdENTs: All international students must apply Associate in Arts degree (AA): A transfer degree for students planning through the Department of International Services. College transcripts from to attend a four-year college or university after graduation from BCC. non-U.S. institutions must be evaluated through a recognized international evaluation service to be used for admission purposes. Associate in science degree (As): The AS is intended to prepare students for entry into employment. Though not considered a transfer TRANsCRIPTs: All final, official transcripts should be received prior to degree, some transfer is possible. orientation and registration. Degree-seeking students whose transcripts Associate in Applied science degree (AAs): The AAS is designed to are not received within the first term cannot register for subsequent terms. prepare students for entry into employment. The AAS may include courses Official transcripts must be sent in a sealed envelope directly to BCC. If that will not typically apply to a baccalaureate program. you received a GED, you must submit a copy of your scores or diploma. If you hold a college degree from a regionally accredited U.S. institution, a Applied Technology diploma (ATd): The ATD is part of an AAS or AS transcript from the institution from which you received the degree is the degree, is less than sixty (60) credit hours, and leads to employment in a only transcript required. Note: Financial aid will not be awarded until all specific occupation. transcripts are received by BCC. You will not be allowed to register for any college credit courses until proof of high school graduation with a standard College Credit Certificate (CCC): Also known as Postsecondary Vocational high school diploma or equivalent or GED is provided to BCC. Certificate. These programs provide instruction consisting of college-level courses to prepare students for entry into employment. FINAL ACCEPTANCE: Although you may receive conditional acceptance and be permitted to register for classes, final acceptance is contingent upon Postsecondary Adult Vocational Certificate (PsAV): These programs receipt of all required documents, including official high school or GED provide instruction consisting of vocational credit courses to prepare transcript and transcripts of all previous college work attempted. Official students for entry into employment. documents are those mailed directly from the previous institution to Brevard Community College. Non-degree: Students who have earned a standard high school diploma or equivalent and do not plan to earn a degree of any kind may enroll as dIsABILITy sUPPORT sERVICEs: Students with documented disabilities non-degree seeking for up to twelve credits. Students in this category may self-identify and request accommodations by contacting the campus cannot receive financial aid and must meet all course prerequisites. Office for Students with Disabilities: Cocoa Campus (321) 433-7295; Submit Application and Fee to Brevard Community College, Attention: Admissions and Records Office ■ Cocoa Campus - 1519 Clearlake Road, Cocoa, FL 32922, (321) 433-7300 ■ Melbourne Campus - 3865 North Wickham Road, Melbourne, FL 32935, (321) 433-5550 ■ Palm Bay Campus - 250 Community College Parkway, Palm Bay, FL 32909, (321) 433-5175 ■ Titusville - 1311 North U.S. 1, Titusville, FL 32796, (321) 433-5100 BrevardCommunityCollegedoesnotdiscriminateonthebasisofrace,color,nationalorigin,ethnicity,sex,disability,orage initsprogramsoractivities.Thefollowingpersonhasbeendesignatedtohandleinquiriesregardingthenondiscrimination policies: Chief Equity and Diversity Officer, 1519 Clearlake Road George Washington Carver Administration Building, Building 2, Room 202, Cocoa Florida 32922, 321 433-7380 ALL INFORMATION MUST BE COMPLETE, ACCURATE AND LEGIBLE SC-011 P0507 R0510 Page 2 Application Office Use Only: B_____________________ FOR ADMISSION Admit Term: ___________ Received: Before completing the application please read the following directions: 1. Read information on preceding page. 2. Print clearly using black or blue ink only. 3. You must sign page 4. Incomplete forms will be returned. 4. You must complete a Residency Affidavit and submit supporting documentation. ExPECTED TERM OF attendance Year: term: o fall o spring o summer NAME: Print Your Name Clearly As It Appears On Your Social Security Card (Leave a blank box between names) Last Name First Name Middle Name Suffix List any previous name(s) under which transcripts or other records may be received MAILING ADDRESS Street Number and Name Apt # City State Zip Code hOME PhONE NUMBER E-MAIL ADDRESS Daytime PhONE SOCIAL SECURITY NUMBER Federal legislation related to the Hope Tax credit (Federal Register, June 16, 2000) requires that all postsecondary institutions report student SSNs to the Internal Revenue Service. contact PERSON – IN CASE OF EMERGENCY Last Name First Name Relationship to student Phone Number GENDER DATE OF BIRTh o Female o Male MM DD YEAR EThNICITY o Hispanic or Latino o Not Hispanic or Latino RACE Select one or more races to indicate what you consider yourself to be. o American Indian or Alaska Native o Natve Hawaiian or Other Pacific Islander o Asian o White o Black or African American CITIzENShIP AND LANGUAGE information Is English your primary language?________ If no, what is? _____________________________________________________ Nation of Birth ____________________________________ Nation of Citizenship____________________________________ Are you a US Citizen? o Yes o No If No, Complete the following information: o PERMANENT RESIDENT ALIEN (P) Alien Registration Number ______________________________________________ If you are a permanent resident alien, you must provide an original or certified copy of your permanent resident alien card. o NON-RESIDENT ALIEN (A) What VISA do you presently hold? (Non-US Citizen only) hIGh SChOOL information Do you have a high school diploma or GED? o Yes o No If Yes, please check one If No, please check one o Standard high school diploma o I am still in high school o Special Diploma* o I am not a high school graduate o Certificate of Completion* o State issued General Education Diploma (GED) Which state issued your GED?_____________________________ Date issued (Month/Day/Year) __________________________________ You must submit your GED scores and/or certificate with this application *Studentsadmittedwithaspecialdiploma,certificateofcompletion(exceptspecificCPT-eligiblecertificatesofcompletion)orasanon-high schoolgraduatemustearnastate-issuedGEDbeforepursuinganassociate’sdegreeorcollegecreditcourses. date OF hIGh SChOOL graduation: (Month/ Day/ Year) _____________________________________________________ hIGh SChOOL NAME _________________________________________________ state ___________________ hIGh SChOOL CODES: Please check the box next to the high school from which you graduated or are currently attending. [ ] Did Not Graduate (000090) [ ] Merritt Island High School (054011) [ ] Other Florida High School (990004) [ ] Astronaut High School (050161) [ ] Palm Bay High School (052021) [ ] Non- Florida High School (990005) [ ] Bayside High School (052211) [ ] Rockledge High School (051011) [ ] Florida Equivalency Diploma (990007) [ ] Cocoa High School (051121) [ ] Satellite High School (056011) [ ] Other Equivalency Diploma (990008) [ ] Cocoa Beach High School (055011) [ ] Space Coast Jr./Sr. High School (050302) [ ] Florida Private High School (990012) [ ] Eau Gallie High School (053011) [ ] Titusville High School (050011) [ ] Non-U.S. High School (990006) [ ] Edgewood Jr./Sr. High School (054021) [ ] Viera High School (051171) [ ] Home School (990015) [ ] Melbourne High School (052011) [ ] West Shore Jr./Sr. High School (053141) FOR hIGh SChOOL STUDENTS IN AN accelerated EDUCATION PROGRAM only: I am still enrolled in high school and am participating in one of the following programs: o Dual Enrollment o Early Admissions o Credit in Escrow Expected High School Graduation Date_______________ High School__________________________________________ PREvIOUS COLLEGE information Did you attend another college or university? o Yes o No List, in chronological order, each college/university you attended even if you withdrew