Thomas Nelson 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 Lauth 7/1/1991 Thomas Nelson Community College Historic Triangle Campus CRED 2011 Summer between 05/17/2011 and 07/28/2011 Non Degree Transfer (026) N 6159661 757-897-5175 223632619 Heather Ms. Heather Elizabeth Lauth

Campus Class Type Term

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 3705 Captain Wynne Drive Williamsburg VA 23185-1455 United States WILLIAMSBURG Y Northop Grumman 757-812-0298 Timothy Lauth Father 757-812-0298 Female Y No Military Service Native Page 2 of 5 .ecu.

S.Level of high school education High School (graduated or currently enrolled) Jamestown High School Jun 20 2009 Advanced Studies Received Bachelor's Degree Associate's Degree Yes Have never served in the U. Armed Forces? Has your parent lived in Virginia for the last twelve months? For last year your parent: Yes paid Virginia income taxes on all earned income Yes For the last twelve months. citizen? What is your parent's military status? Timothy Lauth & Loretta Lauth Yes Have never served in the U.S. citizen? What is your military status? Whose domicile do you want to use to claim eligibility? Your parent's name: Is your parent a U. military No Is your parent married to an active duty member of the U.S.S. military My parent's domicile School Attended Actual or Anticipated Graduation Date Diploma Type Father's Highest Education Mother's Highest Education Are you a U.S. has your parent held a Virginia driver's license or Virginia DMV ID? Page 3 of 5 .

For the last twelve months. has your parent been registered to vote in Virginia? Yes Yes Page 4 of 5 . has your parent owned or operated a motor vehicle registered in Virginia? For the last twelve months. OfficePhoneDirectory.htm Assigned Plan Administrative Contact Phone Admissions Website The signature of a parent or guardian is required for applicants under the age of 18. you will receive in-state tuition rates. Parent/guardian signature: ________________________________________ Page 5 of 5 .Application Confirmation Date Submitted Emplid Username Tuition Information 03/19/2011 6159661 hel280 Based on the residency information you supplied. Non Degree Transfer (026) Admissions Office 757-825-2800 http://www.

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