INDIAN RIVER COMMUNITY COLLEGE eee Application for Admission Entered By; Return Application to: Educational Services Division 3209 Virginla Avene Camp Fogg Pigg gL 34981-5596 COMPLETE KACHLITEM. TyPE On PRMD WLC PA 2 AI" ‘you are ltrestd in aunt Aldo Veern’s bent las contac the Fnac Ald Social Security/ID Number Ottis on the Mala Campus. Any applant with» Gu omy contat the Stet Duby Serva OMe on ih Nain CansAeGRS DL eka! Savi Dison. bJ-fi8)- Tast Name = Tegal mame in | Sup ra ame Midi full) Ma een Sr., Il, etc.) Omac 3 a f Previous Name(s) Maili iress: St jdress or PO Box City State | Zip Code ‘Country ee ate Br Jereen Bead, [PE |ANBE7 3 Permanent Address: Street Address or PO Box (7 City ‘State | ‘Zip Code Country Ey roe " Tiiea Goi] Wosk Pose Pic@gan 432 repr @retog 855, | MAGES Is sescite | Woes ‘Your response ty Gena, Race, and Kihniciy be vtantary? Country of Birth: 45, 5 Gender: ‘Race: ‘Ethnicity: _ New Nock | Sinner (A) Asian ‘G2 Hispenic ‘Country of | Ceeeneie (B) Black or African American Non-Hispanic Bs (1 @premate |] (1) American india Alaskan Native Date of Birth: (P) Hawaiian or Pacific Islander Vous | aie | al | €W) White Taanigration Stats Now US. chia must oobmT “dnislons Check One original documentation of immigration papers or visa (H) High School Graduate or General Education Diploma (GED) earned for copying. (©) Concurrent HS/College student. Non-dual enroilment (7) Transfer-a student who has previously attended a college, university (US. Citizen a technical school other than IRCC (A) Asylee or Applicant for Asylum OC) Transient- « student attending ancther institution who has (F) Fl Visa Student permission from that institution to attend IRCC. (P) Permanent Resident Alien A~ LD (©) Other- none of the above apply (V) Visa Student other than F-1 Enrollment Status: Check One (R) Refugee os ‘New Student 1) © Returning RCC Student Intended Program of Study: Select ONE program and write the code on the line below. See the catalog for program codes. Associate in Arts Degree Associate in Science Degree Associate in Applied Science Degree Technical Certificate ~ Advanced Technical Certificate ~Vosnion|Serifeue __ 305] 9¢mploymenvNon-Depee ‘High School _ or GED, igh school graduates should have an official transcript reflecting high school graduation date seat i the Admissions OFF ‘on the Main Canipas, or present an ofginal GED state diploma and seore report prior to or during your first term of enrollment. ‘Name of High School : 1 City : ‘State | Country A = meus iFuU USA Month Day Yea Seckiato VAce [stuck |F nn as: "ior Clogs Aenean iri a eto ie Hw aio Fea ae An urease a tc anid ne Pal ll Sopa bs Nase of Scholar Caos Sour [County [Dara Ea City Adult education SOS CC TUs A [Hic Slac Applied Technology Diploma (0 Personal/Non-Degree ‘Graduation Date Please indicate whether your parent(s) or legal guardian() have completed a baccalaureate degree: LiMother [rather []Legal Guardian [_JNone of these 1 cet tat alle infornasion submited fo this appicsion is ue tothe best of my knowledge. I understand that any mitreresetaton of facts may esl inthe immnedia cancellation of my aplication or registration. If admitted, I gree to abide by the policies ofthe Board of Trustess and the rules and regulations ofthe college. [understand that itis my responsiblity that high school andlor postsecondary vanscipts are forwarded. Lagsee to the selease ofall ansedpts and test seoces to IRCC, including bot not limited to SAT, Achievement Tests, and ACT score reports that IRCC iy request from other educational instintions. school aistcs, the College Boar ce ACT Sanaa heat ; Sigua of Parent Mapa Gaandint stator se 1S : tage ica seperate pate: 7/2303 LOE 7 ae __Date: ~ Le IRCC 132 (Rev. 11/02) ¢ PLEASE FILL OUT REVERSE SIDE <>"A Florida “resident for tuition purposes" is a person who has, or a dependent person whose parent or legal guardian has, established and maintaie< ‘baat resdency in Florida for at least twelve months, Residence in Florida must be as a bonefide domicile rather than forthe purpose of maintaining Tegal residency i tp enrellment at an institation of higher education. To qualify as a Florida resident for tuition purposes, you must be a U.S. Citize nent esi centalion legal len grated defines by heli gratonandNataraton Serves, One Pee ‘notmesting the twelve-m0r gal recence requirement may be classified ay Fonda residents for futon purposes ony if they fall within pne of the limited special categon Hee eal iy the Honda Legislature and Board of Regents. All other persons are ineligibie for classification as & Florida “resident for tition purpose: Fae re ey eeding school ia Florida will not, in itself, establish legal residence. Students who depend on out-of-state parents for support are presum to be legal residents ofthe same state as their parents. ‘Non-Florida Residents ‘understand that I donot qualify as Florida resident for tuition purposes forthe term fr which this application is submited and tha if should qualify for sor Fae ra rl be necessary forme o file the required documentation prior tothe beginning of the term to be considered for Florida residency clasificatic Name of Student: Social Security Number: Relationship to student: ‘Name of person claiming non-residency: Signature of perion claiming non-Florida residency status: Date: Florida Residents This section must be completed in full f you claim Florida residency for tition purposes. 4 Attach a copy of document(s) required. $ ANSRAESStetyouraglr ont ptrs’ mosses etter ote dacunenain sy eregue eb pedensindeenen Pere ty for whom SO% oF more of hivher supports provided by another as defined by the Inteoal Revenve Service. Independent: a person who provided rore than 50% of iver owa suppor. 4 Aciny bf murrloge derufieate is Fequired in all cases of spouse claiming partners residency. Oo Aree ederendent person and have maintained legal residence ia Florida for at least {2 months, Dg a an aepetpetpon aod my parent or legal guacdian has maintained legal residence in Florida for at leat 12 months. EER, Fame dependent vom no Reg istce for five years with an acl relative other than ray pareat o legal guarcin; and my relative bse ial eeacin soit mo eqles Copy onetime wercimst ae sn Srother proof of dependency 12, Pansat pron Wh has msnsined gal resiensia lsd fates 12 months. Thavenow rabid ealresienesandin qo make Florde my permanent home. (Required: Copy of mariage certificate.) eae ri ry ta Florida tate institution tad classified a a Fora resident for tition purposes. Labsndoned my Floride domic dees than 12 months ago and am nov re-establishing Florida leal residence. CF ean me Unted Sates tnnigrason nd Neturalination Service, Lama permanent resident allen or other legal alien granted ndefin According othe mained a domicile n Fonda fora lest 12 months. (Required: INS documentation and proof of Flos residency sas eee ma Re ceaned services of te United States andl am staioned ia Florida on active militar duty pursuant to military orders, soehgetexrd «Fok otanarembersapeseordeyeode'e issued: Cop otro er D298 towns of record) cow 72202 sine instructional or administrative employee employed by a Florida public school, community college or institution of hig] Tam fon or am the employee's spouse or dependent child, (Required: Copy of employment verification.) 1 esto. ule Palin American/Caribbean Scholarship program (Required: Copy of scholarship papers) BX fam E gaged beaeely one te ene oe aria reat Clete Prowran 240.551, FS), and nt otherwise eligible. required: copy of card) cox, (reaultea: CoP! Guay of Panama and have completed 12 consecutive months of college work tthe F.S.U. Panama Canal Branch, or Hany on cose or dependent child. (Required: Copy of marriage certificate or proof of dependency’) eee na eet state agency or political subdivision ofthe state whose student foes ae paid by the sae agency or poli ubaivsion for the purpose of job-related law enforcement or corrections traning DM. Tama fullumestodent paricipcing in kage institate (8.240.137, #8.) Person claiming Florida residency should complete this section in full. Document siportng the estbishment of gal esgence must be dled issued or ed 12 month efor py ipeay cows ey eric Fos resident classification is sought. AU documentation is subject to verification, t ‘+ Additional documentation other than what is required above may be requested in some cases. corotswine (2 tas. a een = nt Social Seouiy umber: OF, 01 2h 12454 le of person claiming Florida residency: Ge ddtg up Ha tee Jaimant's relationship to stodent ‘Cuimant's permanent gal ade: is © ctaian'swhptone minber( 272) £72 = 2264 SeeeIPO Boe it We ww Sale Tip ie 1, Date claimnat began esublishing legal Frida residence and domicile; Cam voter regstratln: Ste _ Number coun: dssveDees___ 1 Jcrimant's driver's teense: states Ac Number _M 35 0 = =3L2.0 Issue Date: post © Chimaats veice registration: State: fF L.. Tap Number UB G2 tt — nedate FP — REO. oo-US. Cee ony Resieot Alles Numbec ee (Gh copy ofboth sides ofthe Resident Mion Card vequiredy 1 do bereby swear oar hath shove naedgtudent ects al equremens indicated nthe checkedctegary above for lassication asa Foiaresident for wou purposes. tundess than Tin senate tpi wi 586 jer eo penal for making false statemestparsant to $37.06, Florida Statutes, nd to BOR Role 66.0080, FA. _ Junkers ‘Date in reside (as listed inte #3 above) tOrida residertcy (as [sted in tem * oe, mmc 1s0Aherin 3