General Information

First Name:*

Middle Name:*

Last Name:*

Mailing Address:*

City:*

State:*

Zip:*

County: 

Date of Birth:*

E-Mail Address:*

Home Phone:*

Cell Phone:*

High School Graduation Year:*

Indicate your student status:

I am a:_________ (Select One)

Select One Freshman Transfer Student

I would best descibe myself as a:_____________ (Select One)

Select One High School Student Adult Learner

I am interested in Distance Learning - Online Courses: (Select Yes or No)

Select One Yes No

Indicate semester and year you are interested in attending Edgecombe Community College:

Semester:

Select One Fall Semester Spring Semester Summer Term

Year:

Select One 2008 2009 2010

Programs of interest for which you would like information:

Program of Interest:

(Choose one program)

Programs:

Select One Business - Accounting - Business Administration - Computer Information Technology - Networking Technology - Office Systems Technology College Transfer - Arts - Fine Arts - General Education - Pre-Engineering - Sciences Health Sciences - CT/MRI - Dental Assisting* - Dental Hygiene* - Health Information Technology - Interventional Cardiac/Vascular* - Medical Assisting - Medical Transcription - Nursing - Radiography - Respiratory Therapy - Surgical Technology Industrial Programs - AutoBody Repair - Automotive Systems - Biotechnology* - Electric Lineman* - Electrical/Electronics - Facility Maintenance - Industrial Systems - Manufacturing - Mechanical Drafting Service Programs - Cosmetology - Criminal Justice - Early Childhood - Esthetics - Funeral Services* - Human Services - Lateral Entry Teaching - Manicuring/Nail Continuing Education - Basic Skills (ABE, AHS, GED) - Hispanic/Latino Initiatives - Human Resources Development - Special Prohrams - Workforce Development Undecided at this time

Continuing Education:

(Specify course interest)

Please enter any comments or special interest here:

Date: