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Western Piedmont Community College

Reactivation Form

Please complete this form accurately.  Fields designated with and "*" are required fields.

Requestor Information
Last Name: *  
First Name: *  
Middle Name:  
Maiden Name:  
Date of Birth: *   (Ex.  04/22/1992)
Street Address: *  
City: *  
State: *    If other, enter State Code:     
Zip Code: *    (Ex. 28655 or 28655-0881)
Telephone: *   (Ex. 828-438-6000)
Alternate Telephone:   (Ex. 828-438-6000)
Program of Study:  

(Ex. Associate in Arts; Electrical Engineering Technology)

Re-entry Semester and Year: *                 
Have you attended any other schools since applying? *     Yes  No
If yes, please list all schools attended:

* If it has been one year or longer since applying to or attending the college, you will be required to submit a new application.  Visit www.wpcc.edu and click "Apply Now."


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