Adult Degree Completion Program Application

Have you ever visited Chowan University?

Enrollment Status

Anticipated Enrollment Term *

Anticipated Enrollment Year *

First Name *

Middle Name

Last Name *

Have you gone by any other names?

Email Address *

Phone *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Social Security Number

Gender *

Birthdate *

Citizenship

Religious Affiliation

Marital Status

Ethnicity

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)

Permanent Contact Information

Permanent Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Permanent Phone *

Additional Phone

Email Address *Please provide a personal email address you have reliable access to.

Who is your current employer?

What is your occupation?

Work Phone

Emergency Contact

First Name

Last Name

Emergency Contact Number

Education

What is the highest degree you've earned?

College/University 1 Name

College/University 1 City

College/University 1 State

Beginning Attendance Date

Ending Attendance Date

What degree have you earned?

GPA

College/University 2 Name

College/University 2 City

College/University 2 State

Beginning Attendance Date

Ending Attendance Date

What degree have you earned?

GPA

Submission

Have you ever been convicted of a felony? *

Please explain the circumstances of your felony conviction *

Signature