Dual Enrollment Application If you are currently a high school student and wish to earn college credits BEFORE you graduate from high school, you should complete the Dual Enrollment Application form below. If you are currently a high school student or high school graduate and wish to apply to PCCC to begin classes AFTER you graduate from high school, go to www.pccc.edu/applytoday to be linked to your on-line application for admission to the College. If you are not sure which application you should complete, contact the Office of Admission at firstname.lastname@example.org Student Information *First Name *Last Name Middle Name/Initial Other name (if any) Social Security # *Address 1 Address 2 *City or Town *State -- Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *ZIP code *Date of Birth year 2050 2049 2048 2047 2046 2045 2044 2043 2042 2041 2040 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 *Phone Number *Phone Number Type -- Home Cell *Email Address *Parent or Guardian Email *Can we add this email address to our mailing lists? -- Yes No First Name of your Parent/Guardian Last name of your Parent/Guardian Country of Birth -- Afghanistan Albania Algeria Antigua Argentina Bahamas Bangladesh Barbados Bolivia Bosnia Brazil Bulgaria Chile China Colombia Costa Rica Croatia Cyprus Dawlat Qatar Denmark Dominican Republic Ecuador Egypt El Salvador England Ethiopia Finland France Germany Greece Haiti Honduras Hungary India Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kenya Kuwait Latvia Lebanon Liberia Libya Macedonia Mexico Morocco Nicaragua Nigeria Norway Pakistan Palestine Panama Paraguay Peru Philippines Poland Romania Russia Saudi Arabia Scotland Serbia South Africa South Korea Soviet Union Spain Sri Lanka St. Vincent Sudan Sweden Syria Taiwan Thailand Togo Trinidad and Tobago Tunisia Turkey Ukraine United States Uruguay Venezuela Vietnam West Indies Yemen Yugoslavia Zaire Zambia What is your primary language? -- Albanian Arabic Bangla Bulgarian Chinese Creole English French German Gujarati Hindi Italian Japanese Korean Other Polish Portuguese Russian Spanish Tagalog Tamil Turkish Ukranian Urdu Location *Location -- Main Campus, Paterson Wanaque Academic Center Passaic Academic Center PCCC Public Safety Academy, Wayne My High School *Intended Starting Semester Spring 2018 Fall 2018 High School Information *High School CEEB Code Look it up Search Tips High School Name: High School City: High School State: No Selection Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Micronesia Guam Marshall Islands Northern Mariana Islands Palau Virgin Islands, U.S. Armed Forces Americas (Except Canada) Armed Forces Canada, Europe, Middle East, Africa Armed Forces Pacific Puerto Rico Processing ... Please wait ... *High School Name *Expected Year of High School Graduation -- 2017 2018 2019 2020 Do you plan on attending PCCC when you graduate High School? -- Yes No I certify that the information on this application is correct and true to the best of my knowledge. I understand that the submission of false information may result in dismissal from the College. In addition, I understand that upon my enrollment, I will abide by the policies and regulations of the College. I understand that by registering for a PCCC course I am creating a permanent college record. I understand that course content and assignments are determined by PCCC faculty and geared to a college age audience. The Family Education Rights and Privacy Act (FERPA) protects the privacy of student educational records, regardless of age. I give permission to PCCC and waive my privacy rights for academic and conduct information to be shared with the high school and parents or legal guardians. *Click here to agree: Ethnicity (Optional) Both the State and Federal Governments periodically require that we submit information on the characteristics of our students. Your response to this section is voluntary, but will help us in implementing our affirmative action policy. PCCC is an equal opportunity institution. This information does not affect admission or placement. Are you Hispanic or Latino? -- Yes No Select on or more of the following to describe yourself. American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White No person acting within the scope of his or her authority and responsibility at Passaic County Community College shall discriminate on the basis of color, age, race, creed, sex, sexual orientation, national origin, ancestry, disability, marital or veteran's status.