Fields in BOLD are required fields.
Please fill out the form with as much information as possible. 
The more accurate information we have, the faster your application records will be complete.

Last Name:        

First Name:         

Middle Name:   

Maiden Name:  

Social Security Number (no dashes please): 

Note:  The information concerning race and religion is needed for statistical purposes only.
Please refer to our disclosure below.

Race:                                     select from menu African-American Asian Caucasian (White) Hispanic Native American Other

Date of Birth:                          

Sex:                                       Female     Male

Marital Status:                        Single    Married    Divorced

Legal Physical Address:           

City, State, Zip:                  City:    

                                        State:    

                                           Zip:    

County:                  
Country of Citizenship:                      

Country:         US    Other:

If your mailing address is different than your legal physical address, please provide the address in the mailing address fields below.

Mailing Street Address:   
City   
State       Zip

Home Phone:     

Email Address:   

High School: (Please send high school transcript)   
Is this high school located in the state of Mississippi?  Yes    No

Graduation (Month, Year)  

If not high school graduate, when did you complete the GED (Month, Year) - send copy of scores

GED completion date: 

Did you take the GED in Mississippi?   YES      No   

If GED was not taken in MS, what state?  

Have you taken the ACT?                                Yes    No

Did you send a copy of the ACT to ECCC?     Yes    No   (If "No" please send copy)

Have you ever attended ECCC?                    Yes    No   

If Yes, when?   

Name on your record when attended ECCC:  

Parent, Spouse, or Guardian:        

Home Address:    

Have you ever attended another college (send transcript from each college)?  Yes   No

If "Yes," what college(s) did you attend?   

What semester do you plan to attend ECCC?    Fall    Spring   Summer

                                                                          Year:  select from menu 2007 2008 2009 2010 2011

Program of Study Desired:                     

IMPORTANT!

Electronic Signature below is required...

In lieu of a signature, your initials and date of birth are required for verification of your application for admission.

By entering your first and last initials, and the month, day, and year of your birth, you are affirming that the information provided in your application to East Central Community College is true and correct.

First Name Initial:                                       

Last Name Initial:                                      

Birth Month (2 digits, e.g. 05, 11, etc.)        

Birth Year (4 digits, e.g. 1984, etc.)             

East Central Community College is accredited by the Commission on

Colleges of the Southern Association of Colleges and Schools (1866

Southern Lane, Decatur, Georgia 30033-4097:  Telephone number 404-

679-4501) to award the Associate Degree.

_______________________________________________

East Central Community College does not discriminate on the basis of

race, color, religion, national origin, sex, age, or handicap.  The College

is in compliance with the Title VI of the 1964 Civil Rights Act, Title IX of the

1972 Educational Amendments, Section 504 of the Rehabilitation Act of

1973, and the Americans with Disabilities Act of 1990.