Adult Degree Completion Program Application Section 1: Anticipated Enrollment Information 1. Have you ever visited Chowan University? Yes No 2. Anticipated Academic Enroll Year * - Select -20192020 3. Anticipated Academic Enroll Term * FallSpringSummer 4. Which campus would you like to attend? - None -Halifax Community College CenterMain Campus 5. Enrollment Status Part Time Full Time 6. How did you hear about the Chowan University ADCP - None -MailingEducation/Job FairFriend/FamilyRadioWebsiteEmployerOther 7. Prefix - None -Mrs.Ms.Mr.Dr. 8. First Name * 9. Middle Name 10. Last Name * 11. Suffix - None -Jr.Sr.IIIIIIVVVIVII 12. Preferred Name 13. What is your birth/maiden name? 14. Date of Birth (mm/dd/yyyy) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 15. Social Security Number Format: 123-45-6789 16. Gender * - Select -FemaleMale 17. Religious Affiliation - None -African Methodist/EpiscopalAgnosticAnglicanApostolicAssemblyBaptistBrethrenBuddhismCatholicChristian/non-denominationalChurch of ChristChurch of GodDisciples of ChristEpiscopalEvangical Free Church AmericaFreewill BaptistFreewill IndependentHinduHolinessJewishLatter Day SaintsLutheranMennoniteMethodistMissionary BaptistMoravianMormanMuslimNazareneNon DenominationalNone SpecifiedOrthodoxPentecostalPresbyterianProtestantQuakerRoman CatholicSeventh Day AdventistSouthern BaptistSpiritualist 18. Citizenship - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe 19. Ethnicity - None -Hispanic/LatinoNot Hispanic/Latino 20. Race American Indian/Alaska Native(Original Peoples of the Americas)Asian (Including Indian subcontinent and Philippines)Black/African American (Including Africa and the Caribbean)Native Hawaiian or Other Pacific Islander (Original Peoples)`White (Including Middle Eastern) To select multiple option, hold down the sift key. 21. Marital Status - None -SingleMarriedDivorcedWidowed Permanent Address 22. Permanent Address Line 1 * 23. Permanent City * 24. Permanent State * 25. Permanent Zip Code * 26. Permanent Country BahamasCanadaUnited States 27. Permanent Phone Number * Format: 123-456-7890 28. What is your mobile/cell phone number? Format: 123-456-7890 29. Email Address * Format: x@x.xx 30. Who is your current employer? Occupation 31. Work Phone Number Format: 123-456-7890 32. Emergency Contact Name First Name Last Name 34. Emergency Contact Phone Number Format: 123-456-7890 35. What is the highest Degree you've earned? - None -Associate of ArtsAssociate of ScienceBachelor of ArtsBachelor of ScienceCertified Public AccountantDoctorateGED certificateHigh School DiplomaJuris Doctor (Law)Master of ArtsMaster of ScienceMasters of Divinity College/University Information College/University 1 36. College/University Attended 37. College/University City 38. College/University State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming 39. Beginning Attendance Date College/University Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 40. Ending Attendance Date College/University Attended Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 41. What degree have you earned? 42. College GPA College/University 2 43. College/University Attended 44. College/University City 45. College/University State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming 46. Beginning Attendance Date College/University Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 47 Ending Attendance Date College/University Attended Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 48. What degree have you earned? 49. College GPA 50. Have you ever been convicted of a felony? * Yes No 51. Please explain the circumstances of your felony conviction Condition of Admission * To the best of my knowledge, all items in my application have been answered correctly and completely. I understand that providing false, misleading, or incomplete answers may prevent my admissions to Chowan University and/or terminate my subsequent enrollment. Furthermore, I understand that it is my responsibility to notify Chowan University promptly should any information contained herein change prior to enrollment. By submitting this application I agree to these terms.
