HAVE YOU APPLIED FOR THE UPCOMING FALL ADMISSION AND/OR ATTENDED NCC?
q
Yes
q
No
Your Social Security Number
– –
(Enter your United States of America SSN. This number is condential and, under federal law, it is protected and will not be disclosed to unauthorized parties. Disclosures may be
authorized for the purposes of state and federal nancial aid, Hope Lifetime Learning tax credits, institutional assessment, academic transcripts, or accountability research.)
Name
Last __________________________________________________________________ First _____________________________________ Middle _______________________
Permanent Address:
House number and Street _______________________________________________________________________________________Apt. # ______________________________
City ______________________________________________ State _______________ Zip _____________
How long have you resided in Nassau County? ____________ Years How long have you resided in New York State? ________Years
Home Telephone: ( ________ ) __________ – ______________ Cellular Number: ( ________ ) __________ – ______________
Area Code
Gender:
q
Male
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Female
Date of Birth: __________/___________/__________ (MM/DD/YYYY)
Citizenship Status (CHECK ONLY ONE):
Citizen of the United States of America:
q
Yes
No (Country of citizenship ____________________ and check your status below)
q Legal permanent resident of the United States (Attach a copy of your permanent resident card
q Have a visa (please identify) A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, R, S. T, U, V (Attach a copy)
q Status Pending __________________________________________________________
q Other (specify)__________________________________________________________
Ethnicity & Race (optional):
q
White (Non-Hispanic)
q
Black or African American (Non-Hispanic)
q
Hispanic/Latino
q
Asian
q
Native Hawaiian or other Pacic Islander
q
American
Indian or Alaskan Native
q
Two or more races
If you are Hispanic/Latino, is your background (select one)
q
Central American
q
Cuban
q
Dominican
q
Mexican
q
Puerto Rican
q
South American
q
Other Hispanic/Latino
Have you ever been convicted of a felony? (see instructions)
q
Yes
q
No
Your e-mail address (print clearly) : _____________________________________________________________________________________________________________
High School : ___________________________________________________________________________ Expected graduation date :_________________________
Have you attended a New York High School for at least 2 years?
q
Yes
q
No
Are you currently a member of the U.S. Armed Services or a dependent of a service member?
q
Yes
q
No
I declare that all statements made in this application are, to the best of my knowledge, true and correct. I understand that if I was born on or after January 1, 1957 and if I enroll for
6 or more chargeable credits, I must provide the College with proof of immunization against measles, mumps and rubella. ALL students regardless of age who are enrolled for six
or more credit hours must ll out the meningitis survey which is available through the Health Center. My failure to comply with this New
York State law within 30 days from the
start of the semester will result in my disenrollment from classes without refund of tuition and fees.
Student Signature: _______________________________________________________________________________________ Date:______________________________
APPLICATION FOR HIGH SCHOOL ENRICHMENT
PLEASE READ THE INFORMATION ON PAGE 2 BEFORE COMPLETING THIS FORM
FOR OFFICE USE ONLY:
Subject Number Title Credits Subject Number Title Credits
1. 3.
2. 4.
High School Counselor Verification:
This applicant is a student at ____________________________________________. Permission is hereby granted for enrollment in the Summer Session. The courses listed below
will _______ or will not _______ apply toward a high school diploma. A
transcript is attached.
Student Signature: _______________________________________________________________________________________ Date:___________________
Parent Signature: ________________________________________________________________________________________ Date:___________________
High School Counselor Signature: ________________________________________________________________________ Date:___________________
OFFICE OF ADMISSIONS
admissions@ncc.edu
Students with overdue tuition and fees may be referred to a collection agency and will incur additional liabilities of up to 33% to cover all associated collection costs processes. Further,
I understand that the College may have such default information forwarded to credit reporting agencies.
By providing your mobile number you are giving permission to the college to send you text message notications.
05/2020
Area Code
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