Quinsigamond Community College • www.QCC.edu • email: email@example.com
The following information, which is voluntary, will help us to better know our student body and enable us to comply with governmental statistical requests. Responses will not be a
factor in admissions decisions made by the college, but will be made a part of the Permanent Student File, which is protected by Federal and State Privacy Legislation.
n Ethnic and Racial Background
1. Are you Hispanic or Latino?
c Yes c No
2. Please select all that apply: c American Indian/Alaskan Native c Native Hawaiian or other Pacic Islander c Asian
c Black or African American c White c Other________________
3. Please indicate the primary language spoken in your home:________________________________________
n Are you: c Married c Single c Divorced c Widowed
High School (from which you will have graduated)
CEEB # (H.S. Code number if known) cccccc Year of Graduation (actual or anticipated) __________
Major __________________________________________________ Year of Graduation (actual or anticipated) __________
Major ___________________________________________________ Year of Graduation (actual or anticipated) __________
n Are you a United States citizen? c Yes c No If not, please complete the following:
n Are you a Permanent Resident Alien?
c Yes (If yes, list alien registration number: ___________________________) c No
n If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:________________________
n If you are a US citizen or Permanent Resident, please check one of the following (A, B, C, or D)
A. c I have been a Massachusetts resident for six (6) continuous months and intend to remain here.
As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request.
These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high
school diploma). The institution reserves the right to make any additional inquiries regarding the applicant’s status and to require submission of any
additional documentation it deems necessary. Please check-off those documents you possess as proof of your intent to remain in Massachusetts.
c Valid Driver’s license c Utility bills* c Employment pay stub* c Signed lease or rent receipt*
c Voter registration* c State/Federal tax returns* c Mass. High School Diploma c Military home of record*
c Valid Car registration c Record of parents’ residency for unemancipated person* c Other __________________
B. c I do not live in MA but am eligible to participate in the New England Board of Higher Education’s Regional Student Program.
C. c I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.
D. c I am NOT a Massachusetts resident as dened in A.
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall
be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.By applying to the college, I have agreed
to receive phone calls and/or text messages from or on behalf of Quinsigamond Community College regarding their products and
services, at the phone number(s) provided on this form, including my wireless number. I understand that these calls may be generated
using an automated technology.
Applicant Signature: _________________________________________________________________ Date _______________________
Parent/Guardian Signature (Applicant is Under 18 Years Old): _______________________________________ Date _______________________