Fort Peck Community College Phone: (406) 768 - 6300
605 Indian Avenue Fax: (406) 768 - 6301
Po Box 398 www.fpcc.edu
Poplar MT 59255
APPLICATION FOR ADMISSION
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Please submit application to| Fort Peck Community College, Po Box 398, Poplar MT 59255
PLEASE TYPE OR PRINT CLEARLY
Term of Enrollment: Fall Spring Summer Year____________
PERSONAL INFORMATION
Full Legal Name: ___________________ ___________________ ___________________
Last First Middle
Previous Name(s): _____________________________________________________________________
Social Security Number: _____________________________ Date of Birth: _______________________
We ask that you provide this number, which permits the College to distinguish between individuals of the same or similar names.
This is important should you request a transcript at a later date or wish to be considered for financial aid. Social security
numbers will be used for internal purposes only; they are not reprinted on transcripts or any type of academic record or
document.
Permanent address: ____________________________________________________________________
Street
_____________________________________________________________________
City State Zip Code
Telephone Number: ____________________________Cell Number: _____________________________
Mailing address: _______________________________________________________________________
Street
_______________________________________________________________________
City State Zip Code
Email address: ________________________________________________________________________
Marital Status: ◻Single ◻Married ◻Widowed
Are you a Veteran? Yes No
Gender: Female Male
EDUCATIONAL INFORMATION
Have you previously attended Fort Peck Community College? Yes No
If yes, list date of attendance: ____________________________________________
Program of Study: ____________________________________________________
High School Attended (indicate if GED/HiSet) Location Grad/Completion Date
_____________________________________________________________________________________
_____________________________________________________________________________________
Have either of your parents (or guardians) completed a bachelor’s degree? Yes No Unsure
Transfer School Information
If you have attended or are attending a college or university, please provide the following information for
each institution for each institution and whether or not credit was earned:
College Location Dates of Attendance Degree/Credits Earned
____________________________________________________________________________________
____________________________________________________________________________________
ETHNICITY INFORMATION
The following information is requested based on funding provided by the Tribally Controlled Community College Assistance Act
of 1978
Enrolled member of a federally recognized tribe? ◻No ◻Yes If yes, include Tribal Verification Form
Hispanic/Latino Not Hispanic/Latino
If not Hispanic or Latino, indicate which one or more racial categories should be used to classify you:
American Indian/Alaska Native Asian/Pacific Islander
Black/African American Caucasian
Print
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Please submit application to | Fort Peck Community College, Po Box 398, Poplar MT 59255
RESIDENCY INFORMATION
Are you a US citizen? Yes No
Are you a resident of Montana? Yes No
Have you lived in Montana for the past 12 continuous months? Yes No
State in which you claim residency: _______________________________________________________
County in which you claim residence: ______________________________________________________
How long have you lived in this county? ____________________________________________________
Do you file Montana taxes? No Yes Year of most recent tax filing: _______________
Do you have a MT Driver’s License or State ID? No Yes Date of Issue: _______________
SAFETY AND SECURITY INFORMATION
This section must be completed.
1. Have you ever been convicted of a felony (please include instances of deferred sentencing)?
Yes No
2. Have you ever been subjected to court-ordered confinement for threatening or causing physical or
emotional injury to persons or property? Yes No
3. Have you ever been disciplined, suspended from, or placed on probation at any educational institution
for non-academic reasons? Yes No
4. Have you ever been required to register as a sexual or violent offender? Yes No
If you answered yes to any of the questions in this section, you must include an explanation with this
application. An affirmative response to any of these questions will not automatically prevent admission.
Any falsification or omission of data may result in a denial of admission or dismissal.
EMERGENCY CONTACT INFORMATION
Please list person who can legally sign for you in case of emergency.
Name: ______________________ Parent Spouse Other (list relationship): _________________
Address: ______________________ City: _________________ Zip: _____ Phone #: ________________
DISABILITY
If you have a disability requiring accommodation that should be brought to the attention of the Fort Peck
Community College, please submit a request for accommodation to Student Services. Documentation of
disability may be required. All requests regarding disability will be confidential and will not be used as a
factor in granting or denying admissions.
SIGNATURE - RELEASE OF INFORMATION
I hereby authorize the FPCC Registrar’s Office to release any academic information (grades, degree & academic status) to a
FPCC academic or financial program to which I become a participant; as determined by the programs eligibility requirements. I
also grant permission to Fort Peck Community College the right to use, publish, display and/or reproduce any video/recorded
voice or photographs for promotional publication and/or on the Fort Peck Community College website. I also understand that
Fort Peck Community College will own the video/recorded voice/photographs and all rights to them. Please sign and date your
application in ink, as without a signature and date your application cannot be processed.
I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or
misrepresentation. I understand that if it is later found otherwise, it is sufficient cause for rejection or dismissal. If my application
for admission is approved, I agree to abide by the present and future rules and regulations, both academic and non, academic, and
the scholastic standards of Fort Peck Community College, including, but not limited to, those rules, regulations, and standards
stated in both the catalog and student handbook. I further acknowledge that if I fail to adhere to these regulations or meet these
requirements, my registration may be cancelled.
_______________________________________________________ __________________________
Applicant’s legal signature Date
Application for Admissions (revised 6/16/15)
Original Registrar’s Office
Carbon Financial Aid Office
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