Application Signature Page

Reading Area Community College
Application Signature Form

Your application will NOT be processed until a signed copy of this signature page is received.

Name:_________________________________________________________________________________________
Last, First, Middle Initial

Address:_______________________________________________________________________________________
Street, City, State, Zip

Social Security Number :_____________________________

Date of Birth :_____________________________

Phone: (______)_____________________________

___________________________________________________________________
Signature Date

I understand that withholding information requested on this application or giving false information makes me ineligible for admission to the college. I certify to the best of my knowledge that all statements are correct and complete. I understand that discovery of false information is grounds for immediate dismissal and forfeiture of all financial payments and academic credits (NORTH V. WEST VIRGINIA BOARD OF REGENTS AND MERROW V. GOLDBERG). I also agree to abide by the rules and regulations of Reading Area Community College.