Germanna Community College

Application For Admission

Prefix Mister

First Name pipauw

Middle Name

Last Name syah

Suffix

SSN (not specified)

Former First Name

Former Middle Name

Former Last Name

Date of Birth 8/15/1990

College Germanna Community College

Campus Fredericksburg & Nearby Areas

Class Type CRED

Term 2017 Summer between

05/22/2017 and 08/02/2017

Plan Transient Student (025)

Previous Student or Employee N

Emplid 7184161

Primary Phone 765-373-2063

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Street Address 1 63 Overlook Drive

Street Address 2

City Richmond

State IN

Postal Code 47374

Country United States

Current Residence INDIANA

Have you lived in Virginia the past twelve Y

months?

Email raiteicrot@gmail.com

Student's Employer (If Employed)

Business Phone --

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Ethnicity

Gender Male

English is Primary Language Y

Military Status No Military Service

Citizenship Status Native

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Level of high school education High School (graduated or
currently enrolled)

School Attended Christian Academy Of Indiana

Actual or Anticipated Graduation Date 2015

Diploma Type Standard

Father's Highest Education Do Not Know

Mother's Highest Education Do Not Know

Are you a U.S. citizen? No

Are you a permanent resident of the U.S.? No

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 Application Confirmation

Name pipauw syah

Date Submitted 04/20/2017

Emplid 7184161

Username ps27237

Inital password notification sent to raiteicrot@gmail.com

Tuition Information Based on the residency

information you supplied, you
will receive out-of-state tuition
rates.

Assigned Plan Transient Student (025)

Administrative Contact Admissions Office

Phone 540-423-9122

Admissions Website http://www.germanna.edu

The signature of a parent or guardian is required for applicants under the age of
18.

Parent/guardian signature: ________________________________________

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