Passaic County Community College

READMIT-REACTIVATE FORM

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First Name
Middle Initial
Last Name
Date of Birth	mm/dd/yyyy
PCCC 7 digit Student I.D.#
Address
City
State
Zip
Phone
Email Address
Did you Ever Fill Out an Application at PCCC	Yes No
List of Majors
When Do You Want to Return?	*Admission to the College does not guarantee or imply admission to the Nursing or Radiography. These programs have specific admission requirements. Please contact the Admissions Office 973-684-6868 for more information.
College	If You Attended Another College Since you last attended PCCC, list college name and dates of attendance.
Dates Attended From
To
Race/Ethnicity	Both the State and Federal Governments periodically require that we submit information on the characteristics of our students. Your response to this section is voluntary but will help us in implementing our affirmative action policy. PCCC is an equal opportunity institution. This information does not affect admission or placement. (Please click here for definitions of the following designations as indicated in the Federal Register). Please respond to both questions.
Ethnicity (Check one)	Hispanic/Latino Non-Hispanic/Latino
Race (Check one or more)	American Indian / Alaskan Native Asian Black / African American Native Hawaiian / Other Pacific Islander White To submit this form please click the "Send" button below.