Social Security Number  - -

Last Name: First Name:
Middle Name: Maiden or other name used:

Address:
City:    State:      Zip:
 

County (if Mississippi resident)
.
Phone: Day	(Area Code)	- -
Phone: Night	(Area Code)	- -

Your Date of Birth:

Month:  January February  March  April  May  June  July  August  September  October  November  December  Day:  01  02  03  04  05  06  07  08  09  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27 28  29  30  31  Year: 19

Your Age
 

Your Sex: Male Female Your Marital Status: Single Married

Your Race:  *Confidential information requested on a voluntary basis.  Refusal to provide this information will not subject the applicant to any adverse treatment, and the information will be used in a manner consistent with applicable Civil Rights Laws. Caucasian African American Hispanic Native American Asian/Pacific Islander Other Specify (if "Other")

Name: (Last)      (First)     (Middle)
Address:      City:      State:      Zip:
Phone: (Area Code) - -

Relationship to applicant:

Parent
Spouse
Guardian
Other
(specify if "Other")

Type Degree or Certificate you are working toward:

A. A. (Academic)
A. A. S.  (Technical)
Certificate (Career)
Non Degree

Which location do you plan to attend?

Poplarville Campus
Forrest County Center at Hattiesburg
Hancock Center at Waveland
Other
Which location (if "Other")

When do you plan to enter PRCC?

Summer 20
Fall 20
Spring 20
Summer 20

Your High School or GED Information:
 

High School Attended:
High School Address, City, & State:

Did you graduate?

Yes
No
 

Date of Graduation
GED? Please specify state.
Have you previously attended PRCC? Yes No
Dates attended PRCC
Name used when attending PRCC

If you have attended another college or university, please list below:
 

Name of Institution:
Dates of attendance:
Address of Institution:
Credits earned:
Degree earned:
Name of Institution:
Dates of attendance:
Address of Institution:
Credits earned:
Degree earned:
Name of Institution:
Dates of attendance:
Address of Institution:
Credits earned:
Degree earned:

Have you taken the A.C.T.?

Yes
No

When (MM/YY)

Did you have your scores sent to PRCC?

Yes
No

Have you ever been convicted of a felony?

Have you ever been dismissed from another college or university for disciplinary reasons?

If you answer “yes” to either question, contact the Dean of Student Services to schedule an appointment for an interview.  (601-403-1215)

An official transcript of all previous work must be received in the Admissions Office before a student is officially accepted.  Return to: 

The Poplarville Admissions phone number is (601) 403-1214.   

If applying to our Forrest County Center, please send application, transcripts, and ACT scores to: 

The Forrest County Center Admissions phone number is (601) 554-5555. 

Pearl River Community College offers equal educational and employment opportunities to all persons without regard to sex, race, religion, color, national origin, handicap, or age.

I AGREE THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND THAT DELIBERATE FALSIFICATION OF INFORMATION MAY RESULT IN DENIAL OF ADMISSION TO P.R.C.C.

Press the "Send to PRCC" button to transfer this information to Pearl River Community College, Office of Admissions.  If for some reason you do not receive and email acknowledging our receipt of your application within 72 hours, you should resubmit your application, use the printable version of the application, or call 601-403-1197 and request that an application be sent to you by U. S. mail.