Application for Admission

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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

Brevard Community College does not discriminate on the basis of race, color, national origin, ethnicity, sex, disability, or age in its programs or activities. The following person has been designated to handle inquiries regarding the nondiscrimination 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 R0910 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 * Students admitted with a special diploma, certificate of completion (except specific CPT-eligible certificates of completion) or as a non-high school graduate must earn a state-issued GED before pursuing an associate’s degree or college credit courses. 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 or earned no credit. Please do not abbreviate the institution name. List all institutions you have attended. (Attach additional sheet if required.) Please note that official academic transcripts may be required for all colleges you attended or from which you received credit. Official transcripts are those sent directly from the institution to Brevard Community College.

DATES ATTENDED DEGREE NAME OF COLLEGE OR UNIVERSITY CITY STATE FROM TO EARNED Page 4 education goals

1. What is my admissions type? Check all that apply o Readmit student I previously attended BCC as a credit student. I have not attended in two or more years Previous student number or approximate dates of attendance: ______o New student I have never attended college o Transfer student I have attended other colleges and completed college-level credit o Transient student I am enrolled at another college or university and have a Transient Student Form*

o Brevard County Teacher I am employed by Brevard County Schools as a full-time teacher(Employment Letter Required) o Non-degree student I am taking classes for personal enrichment or improvement* o Educator Preparation Institute I have been approved to participate in the Alternative Certification Program of the EPI * Please note that students who are not seeking a degree from BCC are not eligible for financial aid from BCC.

2. What is my Degree/Certificate Intent? (Enter code from list below)

l If you received an AA degree from the State of Florida, you may not receive another AA degree from BCC l If you are unsure about what degree to pursue, visit a Student Advisor or the Career Center l If you are pursuing a limited access program, your initial major will be the AA; once you are accepted into the program your major will be changed.

AA: Associate in Arts (University Transfer) ATD: Applied Technology Diploma AS: Associate in Science PAV: Vocational Certificate AAS: Associate in Applied Science ND: Not Seeking a Degree CCC: College Credit Certificate CER: Educator Preparation Institute

3. What is my intended Major at BCC? See the Major Code list BCC awards only one AA degree; the code is GENR

4. Why am I taking classes? (Enter code from list below) DC: I am seeking a Degree or Certificate CR: I am a Brevard County Teacher TS: I am a Transient Student HD: High School Accelerated Program LA: I am seeking admission to a BCC PE: Personal Enrichment Limited Access Program* JR: Job Related *Each limited access program has an additional application and may have an application fee; contact the department or visit an Academic Advisor. 5. How did you hear about BCC? o Friend/Relative o Newspaper Ad o Radio Ad o TV Ad o Other______o Web o High School Counselor

In accordance with the Family Education Rights & Privacy Act of 1974, a student’s records are the sole property of the student and cannot be released without the student’s permission. The college will honor the student’s written request to restrict the release of “Directory Information.” To withhold information, a student must notify the Admissions and Records Office in writing. Status of disclosure at the last registration period is binding and all records will be noted “Confidential.” No information will be released without the written consent of the student.

Federal legislation relating to the Hope Tax Credit (Federal Register, June 16, 2000) requires that all postsecondary institutions report student SSNs to the Internal Revenue Service. This IRS requirement makes it necessary for community colleges to collect the SSN of every student. A student may refuse to disclose his or her SSN to the college, but the IRS is then authorized to fine the student in the amount of $50. All SSNs are protected by federal regulations (FERPA) and are never released to unauthorized parties. APPLICANT AGREEMENT I hereby apply for admission to Brevard Community College and certify that all information is accurate and complete to the best of my knowledge. If admitted to Brevard Community College, I agree to abide by all the regulations of the college and the laws of the State of Florida. I certify that as a condition of my admission, I will not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance during enrollment at Brevard Community College according to the college’s Drug-Free Policy. I also understand that in order to take courses for credit or to receive credit for courses completed, a copy of my high school transcript is required, along with official transcripts from all colleges previously attended. I further agree to allow my records and test scores to be electronically received from other institutions and/or transferred to the institution of my choice. I understand that my admission to the College may be revoked if it is demonstrated that I have committed any act of academic dishonesty. ______Applicant’s Signature (Required to complete the application) Date

Florida Residency for Tuition Purposes

Florida Residency for Tuition Purposes In order to receive the Florida resident tuition rate, you must be classified as a Florida resident for tuition purposes. There is a difference between being a “Florida resident” and a “Florida resident for tuition purposes.” Presence in Florida for the past 12 consecutive months does not automatically qualify you as a Florida resident for tuition purposes.

Section 1009.21, Florida Statutes, outlines the broad legal parameters for establishing residency for tuition purposes in Florida public higher education institutions. It is the highest level of authority regarding residency as established by the Florida Legislature. This statute also provides authority for the Department of Education to establish rules related to residency for tuition purposes.

Brevard Community College cannot waive State/DOE criteria for ANY reason.

RESIDENCY GUIDELINES

• To qualify as a Florida resident for tuition purposes, the student must be a U.S. citizen, permanent resident alien or a legal alien granted indefinite stay by the United States Citizenship and Immigration Services (USCIS), who has maintained legal residence in Florida for at least the past 12 consecutive months.

• Legal residence in Florida is established when certain legal ties to the state are made. The student must provide evidence that satisfactorily proves that the student (or the claimant) meets the legal requirements to qualify as a Florida resident for tuition purposes. Living or attending school in Florida will not, in itself, establish residency for tuition purposes.

• When providing information for Florida residency for tuition purposes, no single document shall be conclusive. A MINIMUM of TWO documents is required and each must be dated 12 consecutive months prior to the first day of the term in which residency is being requested. Brevard Community College may ask for additional documentation if necessary to establish clear and convincing evidence.

• A student who depends upon out-of-state parents for support is presumed to be a legal resident of the same state as his or her parents.

• BCC is authorized to make discretionary judgments as to residency within the bounds of the law and in reaching this professional judgment will evaluate all documents submitted and information available.

Deadline Dates • The Florida Residency for Tuition Purposes Affidavit and supporting documentation must be submitted to the Admissions Office prior to 5:00 pm on the last day of add/drop for the term in which Florida residency is requested. If student fails to turn in appropriate documentation or does not complete the residency affidavit in full by the deadline date, the student will be considered an out-of-state student. Please refer to BCC’s Florida Residency Guidelines for Tuition Purposes within the college catalog or the BCC website for further information.

• The student will be required to pay the out-of-state rate if in-state residency is not proven by the published tuition and fees due date.

• A MINIMUM of TWO documents is required and each must be dated 12 consecutive months prior to the first day of the term in which residency is being requested.

 I am eligible to be classified as a Florida resident for tuition purposes. Complete Steps 1, 2 and 3.

 I am not eligible to be classified as a Florida resident for tuition purposes. Complete Step 3 of this document. For a future term, to request reclassification as a Florida resident for tuition purposes you must submit to the Admissions office a completed Appeal for Residency Reclassification Affidavit and a minimum of three valid and current documents for the past 12 consecutive months.

Submit completed residency affidavit with supporting documentation to the Admissions office you chose as your primary campus.

Brevard Community College Brevard Community College Brevard Community College Brevard Community College Attn: Admissions Attn: Admissions Attn: Admissions Attn: Admissions Student Center/Bookstore Ralph M. Williams Student Center Student Services Center General Titus C. Hall Center Building 3 Building 11 Building 1 Building 1 1311 North U.S. 1 1519 Clearlake Rd 3865 N. Wickham Rd 250 Community College Pkwy Titusville, FL 32796 Cocoa, FL 32922 Melbourne, FL 32935 Palm Bay, FL 32909 Phone: 321-433-5100 Phone: 321-433-7300 Phone: 321-433-5550 Phone: 321-433-5175 Step 1 Dependency Status

When you apply for college in the state of Florida we need to know if you are dependent or independent. The determination of dependent or independent status is important because it is the basis for whether the student has to submit his/her own documentation of residency (as an independent) or their parent’s or legal guardian’s documentation of residency (as a dependent). The Claimant must submit his/her documentation and complete the residency affidavit.

To be considered a Florida resident the Claimant must have lived in the state of Florida for at least the past 12 consecutive months prior to the first day of the term in which residency is being requested. All documentation proving Florida residency must be valid and current for the past 12 consecutive months.

Are you?

 Dependent Student: Independent Student Cont’d. • The student is married (copy of marriage certificate required) If you are under the age 24, you will be classified as a dependent • student. A copy of your parent’s or legal guardian’s most recent federal The student is classified as an independent by the Brevard income tax return may be required to establish dependency. Note: A Community College Financial Aid Office step-parent cannot typically be the claimant unless he/she has legally • The student has children or other dependents who live with and adopted or has legal guardianship of the student. receive more than half of their support from the student (copy of most recent federal income tax return listing the person(s) as your Students with a different last name than their parent or legal guardian will dependent required) need to supply documentation to prove relationship: • A veteran of the United States Armed Forces or serving on active • Student’s birth certificate with copy of the parent’s marriage and/or duty (copies of military documents required; example: DD 214; divorce papers to show the progression of name change that differs DD 2058) from student • Both of the student’s parents are deceased or the student is, or was until age 18, a ward/dependent of the court (copies of court Non-U.S. Citizens documents required) • Provide original foreign national documents for the student and the • The student can provide documentation that he/she is not claimed claimant (copies of the documents will be made in the Admissions by the parent/legal guardian as a dependent under the federal Office) income tax code and can document that he/she provides at least 50% of his/her own support for the cost of attendance as defined  Independent Student: by the Brevard Community College Financial Aid Office. This is

A student who meets any one of the following criteria shall be classified exclusive of federal, state, and institutional aid or scholarships. as an independent student for the determination of residency for tuition (copy of your most recent tax return and either a current W2 or latest pay stub showing YTD income are required) purposes:

• The student is 24 years of age or older by the first day of classes of Non U.S. Citizens the term for which residency status is requested at a Florida • Provide original foreign national documents for the student institution (copies of the documents will be made in the Admissions Office)

RESIDENCY EXCEPTIONS - Certain applicants who do not meet the 12-month legal residence requirement may be classified as Florida residents or “temporary residents” for tuition purposes. These exceptions and qualifications categories are as follows. Documentation is required.

 A qualified beneficiary under the terms of the Florida Pre-Paid Postsecondary Expense Program (copy of signed card is required)  A dependent person who has resided for five (5) years with an adult relative other than a parent or legal guardian and relative has maintained legal residence in Florida for at least the past 12 consecutive months. (Attach a notarized letter from the adult relative stating that the student is their dependent and that they “exercise day-to-day care, supervision, and control” of the student, and copy of his/her federal income tax returns or other official documents for the past five years showing the student is their dependent)  A Florida public college/university declared me a resident for tuition purposes. (provide official verification from the institution you attended in the past 12 months)  Previously enrolled at a Florida public institution and classified as a Florida resident for tuition purposes. I abandoned my Florida domicile less than 12 consecutive months ago, and I am now re-establishing Florida legal residence. (attach official verification from the institution)  Military: (provide a copy of military orders, DD 214, DD 2058 or National Guard documents)  Active duty members of the Armed Services of the United States residing or stationed in Florida and spouse/dependent children.  Active duty members of the Florida National Guard (and spouse/dependent children) who qualify under 250.10(7) and (8)  Military personnel not stationed in Florida whose home of record or state of legal residence certificate, DD Form 2058, is Florida and spouse/dependent children.  Full-time instructional and administrative personnel employed by state public schools and institutions of higher education and their spouses and dependent children. (provide a letter of full-time employment verification)  Full-time employees of state agencies or political subdivisions of the state when the student fees are paid by the state agency or political subdivision for the purpose of job-related law enforcement or corrections training. (provide a letter of full-time employment verification)  Full-time student participating in an international linkage institute. (S.288.8175,FS) (letter of verification is required)  Part of the Latin American/Caribbean scholarship program. (provide a copy of scholarship)

If no exceptions apply, continue to Step 2. If an exception applies, provide copy of documentation and complete Step 3.

Step 2 Residency Documentation

Each document must be current and at least 12 consecutive months old or older. Claimant MUST have at least one document from Tier 1 to be eligible for Florida residency for tuition purposes.

Tier 1 Tier 2

Claimant must have at least one item from this list. If claimant does not have two documents from Tier 1, one document from Tier 2 may be used.  Florida Driver License or Florida Identification card (ID card can be used only if there is no evidence of  Florida Incorporation (Proof of Florida incorporation ties to another state; i.e., the claimant cannot must be printed from www.sunbiz.org and status possess a valid driver’s license from another state) must be active for the past 12 consecutive months.) REQUIRED for identification purpose,  Utility bill and proof of past 12 consecutive months regardless of whether this document is being used to prove residency. of payments (Cell/mobile phones cannot be used; service must be current. Letter from service  Florida Vehicle Registration provider or copies of billing statements covering the  past 12 consecutive months is required.) Florida Voter Registration

 Transcripts from a Florida high school for multiple  Copy of lease agreement or notarized letter from years if the Florida high school diploma or GED leasing agent/landlord and proof of past 12 was earned within the last 12 months, (A consecutive months of payments (Lease must be dependent student who attended a Florida high current; copies of prior leases may be used to school for a minimum of two (2) academic years establish 12 consecutive months. Copies of rent payment receipts as proof of payment are required.) immediately preceding his/her initial enrollment in an institution of higher education and graduated  A Florida professional or occupational license (Must from a Florida high school or earned a Florida GED be current and issued for the past 12 consecutive within the last twelve (12) months may use their months; copy of license is required.) high school transcript or a GED transcript as  Documents evidencing family ties evidence of Florida residency.)   Proof of purchase of a permanent Florida home Proof of membership in Florida-based charitable or that is occupied as a primary residence of the professional organizations (NOTE: membership in claimant (Copy of mortgage, deed, proof from a church does not constitute membership in a Florida property appraiser website, or Homestead Florida based charitable organization; membership Exemption is required; contracts/agreements must must be current for the past 12 consecutive be dated 12 consecutive months prior to the proof months. Copy of membership card or letter from charitable organization is required) of Florida residency deadline.)   Proof of permanent full-time employment in Florida Declaration of Domicile (Copy is required; must be for at least 30 hours per week documenting that certified by a Clerk of the Court and dated at least claimant has been employed for the past 12 12 consecutive months prior to the first day of the term in which residency is being requested.) consecutive months (letters from current and past employers on letterhead stating the dates of  Any other document that supports the student’s employment, number of hours worked per week and request for resident status, including, but not limited contact name and phone number are required) to an official state, federal, or court document evidencing legal ties to Florida. (For example: Unacceptable Documents benefit histories from Florida agencies, public • Passport • Tax Returns assistance programs or Department of Juvenile • Social Security Card • Library Card Justice Address Verification form. Letter from • Hunting/Fishing Licenses • Birth Certificate agency/program or statement/summary of benefits • Shopping/Rental Club Card • Bank Statements showing past 12 consecutive months is required.) • Invalid/Expired Documentation • Insurance Cards • Concealed Weapon/Gun Permit

The burden of providing clear and convincing documentation that justifies the institution’s classification of a student as a resident for tuition purposes rests with the student or, if the student is a dependent, his or her parent. For documentation to be “clear and convincing,” it must be credible, trustworthy, and sufficient to persuade the institution that the student or, if that student is a dependent, his or her parent has established legal residency in Florida that is not solely for the purpose of pursuing an education and has relinquished residency in any other state for the past twelve (12) consecutive months prior to classification. FOR OFFICE USE ONLY B# Campus: Term:

Step 3 Florida Residency for Tuition Purposes Affidavit Please print legibly in black or blue ink only

Copies of all documents used to prove residency are required and must be submitted with this form to Brevard Community College prior to 5:00 pm on the last day of drop/add for the term in which Florida residency is requested. All documentation is subject to verification. Additional documentation may be requested.

STUDENT INFORMATION:

Name of Student:______

Telephone Number: ( ____ ) ______- ______e-mail: ______

Student ID No.: ______or SSN: _____ - _____ - ______Non-U.S. Citizen Resident Alien No.:______

CLAIMANT INFORMATION: (Person claiming Florida residency)

Name:______Relationship to Student: ______

Telephone Number: ( ______) ______- ______

Claimant’s Permanent Legal Address: (P.O. Box cannot be used):

______Street City State Zip Month Day Year Date claimant began establishing legal Florida residence and domicile: (The date claimant began living in Florida) M onth Day Year

Driver License or ID: State:____ Number: ______Date of Issue: Month Day Year Voter Registration: State:____ Number______Date of Issue: Month Day Year Vehicle Registration: State:____ Tag #:______Date of Issue: Month Day Year Non-U.S. Citizen Resident Alien Number______Date of Issue: