Central Virginia Community College

Application For Admission

Prefix Mister

First Name Robert

Middle Name Bastian

Last Name Kirby

Suffix Jr.

SSN 160144321

Former First Name

Former Middle Name

Former Last Name

Date of Birth 6/29/1996

College Central Virginia Community

College

Campus CVCC Campus & Locations

Class Type CRED

Term 2018 Spring between

01/08/2018 and 05/07/2018

Plan Develop Skills For New Job

(022)

Previous Student or Employee N

Emplid 7299613

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Primary Phone 570-545-6643

Street Address 1 Cannon Ridge Ct Unit E

Street Address 2 Ct Unit E,

City Dulles

State VA

Postal Code 20101-0001

Country United States

Current Residence NEWPORT NEWS

Have you lived in Virginia the past twelve Y

months?

Email 8cicero.belo.545k@laikacyber.cf

Student's Employer (If Employed)

Business Phone --

Emergency Contact First Name skdjsk

Emergency Contact Last Name sdjksdj

Emergency Contact Relationship Foster Child

Emergency Contact Phone 570-454-3321

Ethnicity

Gender Male

English is Primary Language Y

Military Status No Military Service

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Citizenship Status Native

Level of high school education Home School (graduated or

currently enrolled)

Home School State Virginia

Home School Graduation Date Oct 2015

Father's Highest Education Associate's Degree

Mother's Highest Education Received Bachelor's Degree

Are you a U.S. citizen? Yes

What is your military status? Have never served in the U.S.

military

Whose domicile do you want to use to claim My own domicile

eligibility?

Do you have legal dependents other than a Yes

spouse?

Are you a ward of the court or were you a ward of Yes

the court until age 18?

Are you married? No

Are both of your parents deceased and do you Yes

have no adoptive parent or legal guardian?

Are you financially self sufficient? Yes

Do you have a bachelor's degree and are you Yes

working on a graduate degree?

Have you lived in Virginia for the last twelve Yes

months?

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For last year you: paid Virginia income taxes on
all earned income

For the last twelve months, have you held a Yes

Virginia driver's license or Virginia DMV ID?

For the last twelve months, have you owned or Yes

operated a motor vehicle registered in Virginia?

For the last twelve months, have you been Yes

registered to vote in Virginia?

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 Application Confirmation

Name Robert Bastian Kirby

Date Submitted 01/18/2018

Emplid 7299613

Username rbk23797

Inital password notification sent to 8cicero.belo.545k@laikacyber.cf

Tuition Information Based on the residency

information you supplied, you
will receive in-state tuition rates.

Assigned Plan Develop Skills For New Job

(022)

Administrative Contact Admissions Office

Phone 434/832-7633

Admissions Website http://www.cvcc.vccs.edu

The signature of a parent or guardian is required for applicants under the age of
18.

Parent/guardian signature: ________________________________________

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