Wytheville Community College Application For Admission

Prefix First Name Middle Name Last Name Suffix SSN Former First Name Former Middle Name Former Last Name Date of Birth College Campus Class Type Term 2/24/1968 Wytheville Community College Main CRED 2011 Fall between 08/22/2011 and 12/12/2011 Accounting (203) Y 2227250 276-728-5418 228316808 Patricia L Hash

Plan Previous Student or Employee Emplid Primary Phone

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Street Address 1 Street Address 2 City State Postal Code Country Current Residence Have you lived in Virginia the past twelve months? Email Employer Business Phone Emergency Contact First Name Emergency Contact Last Name Emergency Contact Relationship Emergency Contact Phone Ethnicity Gender English is Primary Language Military Status Citizenship Status

1122 Stoneridge Rd.

Austinville VA 24312-3424 United States CARROLL Y

onlaurelcreek@yahoo.com Carroll-Grayson-Galax SWA 276-728-2511 Glen Hash Spouse 276-733-4461

Female Y No Military Service Native

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Level of high school education

High School (graduated or currently enrolled) Carroll County High School May 24 1986 Standard Wytheville Cmty College Aug 1990 Sep 1995 No degree earned Y

School Attended Actual or Anticipated Graduation Date Diploma Type College Attended From Attended To Degree Type Were you suspended or dismissed from the last college attended? Father's Highest Education Mother's Highest Education Are you a U.S. citizen? What is your military status?

Attended High School Graduated From High School Yes Have never served in the U.S. military My own domicile

Whose domicile do you want to use to claim eligibility? Have you lived in Virginia for the last twelve months? For last year you:


paid Virginia income taxes on all earned income Yes

For the last twelve months, have you held a Virginia driver's license or Virginia DMV ID?

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For the last twelve months, have you owned or operated a motor vehicle registered in Virginia? For the last twelve months, have you been registered to vote in Virginia?



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Application Confirmation
Date Submitted Emplid Username Tuition Information 08/29/2011 2227250 phash0006 Based on the residency information you supplied, you will receive in-state tuition rates. Accounting (203) Colene Kilgore 276/223-4723 wckilgc@wcc.vccs.edu Admissions Office 276-223-4701 http://www.wcc.vccs.edu/ prostudents/application.php

Assigned Plan Advisor Advisor Phone Advisor Email Administrative Contact Phone Admissions Website

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

Parent/guardian signature: ________________________________________

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