Fillable Admission Application (Clovis Community College)

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Admission Application (Clovis Community College)

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  • 77 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for Clovis Community College

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Name of High School/GED:
City & State
Graduation/Completion Date:
Academic Goal
Month/Year
Colleges and/or Universities
(Please list all previously attended)
Location
Attendance Dates
From To
RESIDENCY INFORMATION (REQUIRED)
RACE
Please select one or all that apply:
White
Native Hawaiian
or Pacific Islander
Asian
American Indian
or Alaska Native
Black / African American
ETHNICITY
In compliance with US Department of Education for Title IV
federal requirements, please indicate your ethnic origin.
Hispanic or Latino Non Hispanic or Latino
For office use only
Emergency Contact
Name
Address (if different from above)
Relationship
Phone Number
PERSONAL INFORMATION All student information is kept confidential
Social Security Number
Date of Birth (MM/DD/YYYY)
Male
Female
Street Address
City, State, Zip
Return application to:
Admissions and Records Office
417 Schepps Blvd.
Clovis, NM 88101-8381
(575) 769-4025
Fax: (575) 769-4027
Admission Application
admissions@clovis.edu
New First Time
Transfer
Full Legal Name
Current Mailing Address
City
Email AddressEm
Preferred Phone Numbers:
State
Zip
Last Name
First Name
Middle Name (Optional)
Cell
Home
Other
Cell
Home
Other
Active-Duty Military
Spouse of Active-Duty Military
Dependent of Active-Duty Military
MILITARY AFFILIATION
Please select one or all that apply:
Citizenship Status:
U.S. Citizen
Permanent Resident
Non-U.S. Citizen: Please list country of citizenship:
Yes
No, which state? _________
If you have a current visa, please list visa type and expiration date:
Dates of residence in New Mexico: From _______ to ________
Is New Mexico your legal state of residence?
Yes
Have you lived in New Mexico for the past 12 months?
Do you have a current New Mexico Driver's License or State ID?
Yes
No
No
EDUCATION INFORMATION
High School ID/STARS ID (if known):
Are you interested in receiving Financial Aid?
Enrollment Reason
Which best describes your goal?
Take one or more courses, not pursuing degree at CCC
Complete a certificate program with CCC
Complete a degree with CCC
Check One:
Prepare for Transfer to another institution
Improve personal/professional skills
Prepare for a job immediately after CCC
Yes
No
If yes, be sure to file your FAFSA at fafsa.gov
Please type or print legibly in ink. Complete the front and back. Sign and date the application.
Semester you plan to enroll:
Year: 20_________
Fall
Spring
Summer
Returning to CCC
Student Type:
How Did You Hear About CCC?
Social Media/CCC Website
Radio
CCC Recruiter:
_________________________
Name
Other (please describe): ____________________
Turn over for required signature
ASSOCIATE OF APPLIED SCIENCE
Academy-Based Criminal Justice
Business Administration
Computer Information Systems (Information Technology):
Information Systems and Technology Concentration
Criminal Justice
Emergency Medical Services
Nursing
Paralegal (Legal Assistant Studies)
Physical Therapist Assistant
Radiologic Technology
ASSOCIATE OF APPLIED SCIENCE IN
FULL-TIME OCCUPATIONAL TECHNOLOGY PROGRAMS
Automotive Technology
Cosmetology
Plant Operations and Equipment Concentration
ASSOCIATE OF ARTS
Art:
Fine Art
Graphic Design and Media Art
Early Childhood Education
Liberal Arts:
General Liberal Arts Concentration
Education Concentration
ASSOCIATE OF GENERAL STUDIES
Associate of General Studies
ASSOCIATE OF SCIENCE
Behavioral Science
Business Administration
Computer Information Systems
Health and Physical Education
OTHER
Undecided
Non-Degree Seeking
CERTIFICATE OF COMPLETION
Automotive Technology:
Automotive Chassis Systems
Automotive Power Train Systems
Business Administration
Computer Information Systems:
Information Systems and Technology
Networking
Office Specialist
Cosmetology:
Cosmetology Theory
Hair Fundamentals
Esthetics
Nail Technician
Criminal Justice
Graphic Design and Media Art
Health and Physical Education
Exercise Specialist
Industrial Technology:
Electrical Maintenance
Industrial Technology
Liberal Arts
Paralegal (Legal Assistant Studies)
Practical Nursing
Welding:
Entry-Level Welder
Advanced Welder
CERTIFICATE OF ACHIEVEMENT
Business Administration:
Computer Information Systems:
Cisco Certified Entry Network Technician (CCENT) Cisco
Certified Networking Associate (CCNA)
CompTIA A+
CompTIA Network+
CompTIA Security+
Internet & Computing Core Certification (I
3
)
Microsoft Certified Solutions Associate (MCSA) Server
Microsoft Office Specialist (MOS)
Cosmetology:
Salon Success
Early Childhood Education
Emergency Medical Services:
First Responder
Emergency Medical Technician—Basic
Graphic Design and Media Art:
Fundamentals of Game Design
Health Care Assistant
Plant Operations
CCC Programs of Study
(Effective 2020-2021 Catalog)
REV. 7.7.20
KS
NOTICE OF NON-DISCRIMINATION
Clovis Community College does not discriminate on the basis of race, color, national origin, ancestry,
religion, sex, sexual orientation, spousal affiliation, gender identity, veteran status, physical or mental
disability, serious medical condition, or age in its programs and activities. The following personnel have
been designated to handle inquiries regarding the non-discrimination policies:
Mr. Freddie Salazar, Director of Security
417 Schepps Blvd, Clovis, NM 88101 Room 134
575-769-4144
Mrs. Regina Dart, Director of Human Resource Services
417 Schepps Blvd, Clovis, NM 88101 Room 112
575-769-4045
For further information on notice of non-discrimination, visit https://wdcrobcolp01.ed.gov/CFAPPS/OCR/
contactus.cfm for the address and phone number of the office that serves your area, or call 1-800-421-3481.
Wind Energy
Phlebotomy Technician
Networking Concentration
Industrial Technology:
Wind Enengy Concentration
Welding
Income Tax Preparation
Emergency Medical Technician—Intermediate
Industrial Technology:
STUDENT’S SIGNATURE
Clovis Community College adheres to an open admission policy except for certain occupational programs, including Nursing, Radiologic Technology, and
Physical Therapist Assistant. By submitting this application for admission, you have been provisionally accepted to CCC.
I certify that the above information is true and correct to the best of my knowledge. A student found guilty of NONDISCLOSURE or MISREPRESENTATION in
filling out this application orm may be subject to disciplinary action and possible dismissal from Clovis Community College.
Student’s Signature Date
If pursuing a degree at CCC, please check degree and major above. If non-degree seeking, please indicate that on this form.
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Admission Application (Clovis Community College)

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Completed 20 September 2020

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