Please complete the entire application and submit to complete registration.

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* 1. Social Security Number or Eastern Student ID: 

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* 2. Student Information

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* 3. Date of Birth: Enter MM/DD/YYYY

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* 4. Gender

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* 5. U.S. Citizen:

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* 6. Ethnic Background: 

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* 7. How long have you lived in West Virginia?

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* 8. What high school are you attending?

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* 9. When will you graduate?

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* 10. In case of emergency, notify:

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* 11. I certify that all the information provided in this application is complete and correct to the best of my knowledge. I understand that any false information or omission of information relating to residency, citizenship, or previous college attendance is cause for suspension from Eastern WVCTC. I will also acquaint myself with and abide by the student code of conduct, including compliance with the Drug-Free Schools and Communities Act, and other requirements governing the academic and social standards of Eastern WVCTC.

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* 12. Select below all the course for which you are enrolling:

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* 13. Previous Early Entrance Courses

  Yes No
Have you taken an Eastern Early Entrance Course before?
If Yes, did you complete the Blackboard Training and receive a Completion Certificate?
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