Danville Area
Community College 		       Application/Student Information Form
When completing this form, please print clearly.
1. Name:  (please use your full name as it appears on your Social Security Card)
     Last____________________  First____________________ Middle___________________ 
     Previous Name(s)___________________________________________________________
2. Salutation: (check one)  Mr.  Mrs.  Miss  Ms.
3. Permanent Legal, Home Mailing Address: No. & Street (Apt. No.) or Rural Route & Box Number
_______________________________________________________________________________
City or Town _______________ State (or Country) ______ Zip Code ________ County __________ 
4. Area Code & Phone # (_____)____________________  Home #    Cell #    Message #
5. Social Security Number: ______________/_________/________________
**Social Security Number is a requirement for Federal reporting and possible tax deduction.**
**You will be assigned a DACC ID# for general use.**
6. Date of Birth ___________________________
7. Ethnic/Race Classification:
AN American Indian/Alaskan Native AS Asian BL Black/African American  
HP  Hawaiian/Pacific Islander HIS Hispanic/Latino WH White  
8. E-mail address: ________________________________________________________________
9. Term you plan on starting in: (check one)      Fall 20 ____     Spring 20 ____    Summer 20 ____
10. Name of Major: ________________________________________________________________
  Career/Occupational (To prepare for work world)     Transfer/Baccalaureate (To prepare for transfer to a four year college)
11. Admission Status:
FR First time College Student CCE Corporate & Community Education Enrollee
DUAL Dual Enrollment Student RE-AD Readmitted Student (Attended DACC Before)
TR Transferring from another College    
12. Educational Goal: (check one)
1 - Complete 1 or more course 2 - Complete Certificate (30 plus hours)
3 - Complete Certificate (1-29 hours) 4 - Complete Associate Degree
13. Citizenship or Visa:
U.S. Citizen
In U.S. on a Visa.  Type of Visa: _____________________________________ Please attach copy.
  Country of Citizenship:____________________________________
Expiration Date of Visa:____________________________________
Applying for Student Visa (Please note that we have a separate International Student Application)
Not on a Visa/Not a U.S. Citizen
14. Is English your native language?     Yes     No
15. Are you a veteran?     Yes     No
  Are you a dependent of a veteran?     Yes     No
  Is your spouse a veteran?     Yes     No
16. Institutions Attended:
      High School Attended:  (check the name of the high school you last attended)
Armstrong 140-105 Danville 141-550 Jamaica 143-920 Schlarman 141-555
Bismarck 140-325 First Baptist 141-552 Milford 142-915 Seeger 153-750
Catlin 140-570 Fountain Central 153-580 North Vermillion 150-455  Shiloh 142-318
Chrisman 141-400 Georgetown-Ridge Farm 142-030  Oakwood 141-915 Westville 144-375
Covington 150-655  Hoopeston 142-310 Rossville 143-755  
Other: __________________________________________________ State _______________________ 
High School Information: (check one)
Currently in High School or taking GED classes     Expected graduation date:  Month ________/Yr. ________
Graduated in:  Month and year of high school graduation _____________________________/____________
Graduated:  Month and year of GED awarded (Fill in line below) ______________________/_____________
        County and state where GED was issued ___________________________________________________
Did not graduate or receive GED
List all previous colleges or universities attended
Name of School
City/State
Attended From/To
Date Graduated
 ____________________   ____________________   ________/________   ________/________ 
 ____________________   ____________________   ________/________   ________/________ 
 
17. Emergency Contact Name: Last__________________  First___________________________
                                                    Phone: (        )_____________________

18. Highest Previous Degree Earned: (check one)
N - None S - Some College/No Degree B - Bachelor's Degree O - Other
H - High School C - Certificate M - Master's Degree U - Unknown
CG - GED Certificate A - Associate Degree D - Doctoral Degree
19. Employment Status:
1–Employed full time 
4–Homemaker
7–No Response		 2–Employed part time / 15+ hrs 
5–Unemployed/Retired
 3–Employed part time / 1-14 hrs
6–Other
20. Attendance Goal:
1–Transfer to 4 yr College 
4–Prepare for GED		 2–Improve skills for job 
5–For personal interest		 3–Prepare for job in future
6–Other
21. What is the highest degree/education level your mother/father/legal guardian completed?
Mother
Father
or    Legal Guardian
None Completed 
High School/GED
Some College 
Associate Degree
Bachelor’s Degree

***I VERIFY THAT THE INFORMATION ON THE FORM IS TRUE.
Signature_______________________________________________     Date ____________________ 
FOR OFFICE USE ONLY:
Minimum Admission Requirements for Associate of Arts & Associate of Science Degree Students
0–Not applicable/Not A.S.A., A.E.S., or A.G.S.
1–Yes, through high school coursework the student met all admission standards.
2–Yes, through means other than high school coursework (testing, college coursework, etc.)
3-No, student was evaluated but has not met all admission standards.
4–Not evaluated or data not available.
Term Admission Requirements Met.     1 - Summer 3 - Fall 6 - Spring

Fiscal Year Admission Requirements Met.    Fiscal Year 20_____