Application for Admission to Pearl River Community College

Poplarville, MS 39470.

Contact: Webmaster

Last Update 6-11-07.

Introduction
Fill this application out in its entirety and press the submit button. The Electronic signature at the bottom must be completed for the application to be processed.
Your application will be processed upon receipt. You will receive an email response from the Office of Admissions. If you do not receive an email response within 72 hours, you should resubmit the online application or use the printable application (see link below). AOL users should use the printable application due to AOL''s anti-spam programs that do not allow automatically generated emails. You will need to mail a photocopy of your ACT original scores to the address below (not necessary if ACT scores appear on your official high school or college transcript).

PRCC
Office of Admissions
Box 5559
Poplarville, MS 39470
(ph. 601-403-1214)

Click here for printable credit card authorization form
Click here for a printable application
Click here to download the Adobe Reader.

* Indicates a required field.

Personal Details

First Name:

Middle name:

Last name:

Maiden name:

Social Security Number: - Social Security Number: - Social Security Number:

Date of Birth: Date of Birth: Year of Birth:

Phone Number (Day): - Phone Number (Day): - Phone Number (Day):

Phone Number (Night): - Phone Number (Night): - Phone Number (Night):

E-mail Address:

Address:

City/Town:

State:

Zip Code:

County:

Sex: Male Female

Marriage Status: Single Married

Citizen of the U.S.: Yes No

Race This confidential information is 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.

Specify if Other:

Emergency Contact

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number: - Phone Number: - Phone Number:

Relationship to applicant: Parent Spouse Guardian Other

Specify if Other:

High School Information

High School Attended:

State:

Did you graduate?: Yes No

Date of Graduation(mm/yyyy):

Did you earn your
GED?: Yes No

Please specify the state where you earned it:

Please tell us when you earned it(mm/yyyy):

Have you previously
attended PRCC?: Yes No

Dates attended PRCC:

Name used when attending PRCC:

ACT Test Information

Have you taken the A.C.T.?: Yes No

When (mm/yyyy):

Did you have your scores
sent to PRCC?: Yes No

Colleges and Universities

Institution:

Dates of attendance:

City:

State:

Credits earned:

Degree earned:

Institution:

Dates of attendance:

City:

State:

Credits earned:

Degree earned:

Institution:

Dates of attendance:

City:

State:

Credits earned:

Degree earned:

Authorization for Medical Procedures In the event of serious illness or accident, every effort will be made to contact parents or guardian if student is under age 21. In the event that delay in medical, surgical, or psychological treatment might be detrimental to the health of the student, authorization for consultation and treatment is required.

Permission is granted Pearl River Community College to refer this student for necessary treatment.

Signature of student (age 21and over)

Date: November 7, 2009

Initials:

Date of Birth: Date of Birth: Year of Birth:

Signature of parent or guardian (if under age 21)

Date: November 7, 2009

Initials:

Date of Birth: Date of Birth: Year of Birth:

Address and Phone Number:

Other Required Information Pearl River Community College requires applicants to answer the questions: ''Have you ever been convicted of a felony?'' and ''Have you ever been expelled and/or dismissed from another college or university for disciplinary reasons?'' An applicant who answers ''yes'' will be required to submit additional information and schedule a meeting with the Dean of Student Services. The College reserves the ultimate decision on acceptance or rejection of any application. Applicants should also be aware that an individual with a felony conviction may not be able to obtain licensure in certain professions. In such cases where a felony conviction will prevent the student from applying for state licensure in a specific area, the student will be denied admission to that specific program.

Have you ever been
convicted of a felony?: Yes No

Have you ever been
dismissed from another
college or university for
disciplinary reasons?: Yes No

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:

ADMISSIONS OFFICE
BOX 5559
POPLARVILLE, MS 39470

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

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

PEARL RIVER COMMUNITY COLLEGE
FORREST COUNTY CENTER
5448 U.S. HWY 49 SOUTH
HATTIESBURG MS, 39401

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.

Student Verfication Verification: Type in your initials and your date of birth. By typing in your initials and your date of birith, you are verifying that the information you are sending is true and you wish to be admitted to Pearl River Community College.

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.

Initials:

Date of Birth: Date of Birth: Year of Birth:

Press the ''Submit Application'' 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.

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