Campbell University RTP Extended Campus
Application for Admission
(All sections must be completed)

If any fields or questions in the form do not pertain to you, please enter "N/A".
Do not leave any areas blank as the form will not be submitted.

I hereby apply for undergraduate admission to Campbell University beginnning:
TERM -select-Fall IFall IISpring ISpring IISummer YEAR -select-201120122013

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PERSONAL INFORMATION
First Name
MI
Last Name
Gender -select-MaleFemale
Marital Status -select-SingleMarriedWidowed
Maiden Name (if applicable)
Social Security Number - -
Date of Birth
Place of Birth
Race/Ethnicity
Religious Affiliation (if applicable)
Name of current employer
Have you ever been convicted of a felony? -select-YesNo
If yes, please describe:
Are you a U.S. Citizen? Yes No
If not, are you a Permanent Resident? Yes No N/A
Native Country
Permanent Address
Street/Box Address
City
County
State -select-AKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip
CONTACT INFORMATION
Local Address
Street/Box Address
City
County
State -select-AKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip
How long have you lived at this address?
State of Legal Residence -select-AKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Best Way to Reach You -select-HomeCellWork
Phone Number - -
Email
MILITARY INFORMATION
Are you an active duty family member? -select-YesNo
Are you currently on active duty? -select-YesNo
Guard/Reserve? -select-YesNo
MOS/NER
Select Branch of Military -select-ArmyAir ForceMarine CorpsNavyCoast Guard (if applicable)
Rank -select-OffWONCOENL
Grade -select-010203040506070809E1E2E3E4E5E6E7E8E9
ETS/EAS Date
EDUCATION
Do you plan to apply for federal financial aid? -select-YesNo
Do you plan to use Veterans Education Benefits? -select-YesNo
Do you have a high school diploma? -select-YesNo
If not, do you have a GED? -select-YesNo
If yes, where did you attend high school?
Name of school
City
State -select-AKALAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip
Date of Graduation/Last Attended -day-01020304050607080910111213141516171819202122232425262728293031 -month-JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember -year-2013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950
Do you already hold a college degree? -select-YesNo
If yes, please specify:
What is your proposed degree from Campbell? -select-Associate DegreeBachelors Degree
What is your proposed major from Campbell? -select-Associate of ArtsAssociate of Business AdministrationAssociate of General EducationAssociate of IT/Management ConcentrationAssociate of IT/Security ConcentrationAccountingApplied ScienceBusiness AdministrationIT/Management ConcentrationIT/Security ConcentrationPsychologySocial Science/Criminal Justice ConcentrationSocial Science/Homeland Security Concentration
Are you visiting from another institution? -select-YesNo
If yes, please give Home College/University

List ALL schools attended since high school.{Include trade, business and technical schools, as well as colleges and universities. Do not include military schools.}

How did you find Campbell University RTP? Current Student Friend Family
Co-Worker Online Search Education/Career Fair
Newspaper Radio Advertisement
If other, please specify:

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I CERTIFY THAT THE INFORMATION GIVEN IS COMPLETE AND ACCURATE.

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Captcha Security: Please enter the following code into the box exactly as it appears in the image.

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