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Basic Skills Orientation In-class Registration Form

Orientation section:  

Have you ever been a CPCC student in the past?: Yes No
If Yes, CPCC Student Id number:

Last name:  First name:  Middle name:

Previous (maiden) name:


Street number & name, Apt. Number, PO Box:

City:   State:   Zip:

You are resident of what state?     What North Carolina county?

Home phone:  Cell phone:  Work phone:


Emergency Contact

Name:   Emergency Phone: 

Personal Information

Social Security Number:     Birth Date:     Ethnic Group:      Sex: 

Citizen Information

US Citizen:

Non US Citizen:
Country of Citizenship:    Resident Alien Card Number:   Resident Alien Card Issue Date:


Non-Immigrant Alien:
Visa Type      Do you have difficulty with English because it is not your native language?  No  Yes  

Education History

High School Attended or Other:
     NC High School:
          Home School
     Out of State:
     Foreign Country:

Dates attended:  From  To

Track (Select One)

If you graduated from High School, which type of diploma did you receive? (Select One)
Highest educational level completed (Select One)

Residency Information

I have lived in NC since:  

If you have NOT lived in NC continuously for the past 12 month, in which state or country 

State in which you pay your income tax as resident:

Drivers License or State ID
State:    Number:   Issue Date:    Expiration Date:

Military/Veterans Information

Are you a Veteran? Yes No      Are you eligible for VA Benefits? Yes No 

Are you active duty military or military dependent? Yes  No
If active duty, are you stationed in NC?  Yes   No

If you are active duty, is NC your Home of Record?   Yes  No

If military dependent, what is your Military ID card expiration date? 

Employment Information

Employment status while enrolled:

Goals Information

What is your main reason for attending? (Select one) 
I plan to attend (Check one):  Day   Evening/Weekend   Internet

I certify that the responses in this form are true and complete, and I understand that, if found otherwise, it may be cause for delay or denial of admission, loss of credit or dismissal. I agree to abide by the rules of the college.


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