Application Submitted to: Fayetteville Technical Community College

Application Submitted via www.CFNC.org

Confirmation Details
Confirmation Number 1497−2010FA−5−09102010−12472799−09311898 Date Started 9/10/2010 12:37:00 PM
Date Submitted 9/10/2010 1:20:00 PM Payment Type No Payment

Student Name
Last name: Robertson First name: Steven
Middle name: Anthony Suffix:
Preferred first name: First name:
Last name: First name:
Last name:

Permanent Address
Street: 405 Lantana Ln APT D City: Fayetteville
U.S. state/territory: NC Zip code: 28314
Country: US Int'l postal code:
Telephone Number
where you can best (313) 574−4976 Work telephone: (313) 574−4976
be reached:
Cellular telephone: (313) 574−4976 E−mail address: robertson131@ymail.com

Hidden Fields
Business telephone Home telephone
BU H
type: type:

Permanent Mailing Address

Street: 405 Lantana Ln APT D City: Fayetteville
U.S. state/territory: NC Zip code: 28314
Country: US Int'l postal code:

Applicant Information
Reenter your
Social Security Social Security
075−78−9134 075−78−9134
number: number (for
verification):
NCWISE ID: Date of birth: 01/13/1988
Are you Hispanic
Gender: m N
or Latino?
Select one or more of
the following racial White
categories:

1
 Citizenship
If Non−U.S.
Select the
citizen, select
appropriate U.S. Citizen
country of
designation:
citizenship:
Permanent Resident
Visa type:
number:
Nonimmigrant visa
Issue date:
number:
Have you been
Expiration date: assigned an INS N
SEVIS number?
INS SEVIS number:

Residency Information
If yes, select your
Are you a North
Y county of 26
Carolina resident?
residence:
U.S. state/territory in
U.S. state/territory
which you pay state
NC in which you are
income tax as a
registered to vote:
resident:
Have you acquired a
Y U.S. state/territory: NC
valid driver's license?
Original date
Number: 38254868 04/2010
issued:
Have you lived in
North Carolina
Y U.S. state/territory:
continuously for the
past twelve months?
I have lived in
Country: North Carolina 01/03/2008
since:
What is your primary
EN
language?

Military Service
Are you a veteran? Y If yes, what type? 30
Are you active
Are you eligible for
duty military or a
VA education Y Neither
military
benefits?
dependent?
Where is your duty Where is your
station? home of record?
What is the
expiration date of
Branch of service:
your military ID
card?
Where is your
sponsor's duty
station?

Financial Aid
Do you plan to apply
Y
for financial aid?

2
 Emergency Contact
Name: Michael Robertson Telephone: (443) 616−4322
Family physician: Telephone:

Hidden Fields
Residency status: Student type:

Family Information
Father's Education Mother's
Associate Degree Bachelors Degree
Level Education Level

Enroll
Reason for
Do you plan to enroll: Full−time
Enrolling
Choose the
program of
Do you plan to attend
Day study/major which A45700|Radiography
during:
you are interested
in pursuing:
Indicate the
Education goals
secondary program
(select what is GR
of study which
your primary goal):
interests you:
Employment status
Employed 11−20 hrs/w Employer Name: Salsaritas
while enrolled:
Street: City: Fayetteville
U.S. state/territory: NC Zip Code: 28314
If Unemployed, are Previous
you: Employer:
Which campus do
Date of
you wish to
Unemployment:
attend?
How did you first
learn about the Friend
college?

Hidden Fields
(hidden) A45700 (hidden) Radiography

Enrollment Term
Enrollment term: 2010FA Entrance status: Freshman
Are you a returning
N
student?

Most Recent High School

High school: ANNAPOLIS HIGH SCHOOL CEEB code: 230792
High school type: Public Street: 4650 CLIPPERT STREET
City: DEARBORN HEIGHTS County:

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 U.S. state/territory: MI Country: US
Graduation date or
06/2006 High school track: Track unknown
last date attended:
Did you graduate
Y 12th grade:
from high school?

Education History
Did you receive a
Highest educational GED certificate,
level completed that Graduate of High School adult high school X
best describes you: diploma, or
neither?
School: CEEB:
GED/AHSD
City:
County:
U.S. state/territory: Country:
Date completed:

Other Colleges Attended

College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Dates attended: to:
College/University: CEEB code:
Street: City:
U.S. state/territory: Country:
Date attended from: to:
College/University: CEEB code:
Street1: City:

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 U.S. state/territory: Country:
Date attended from: to:
College/University: CEEB code:
Street1: City:
U.S. state/territory: Country:
Date attended from: to:
College/University: CEEB code:
Street1: City:
U.S. state/territory: Country:
Date attended from: to:
Residency status: