Fillable Applicaon for Admission | Please complete all items (Nashua Community College)

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Applicaon for Admission | Please complete all items (Nashua Community College)

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Applicaon for Admission | Please complete all items and print clearly
___________________________________________________________________________________________________________________
Last First Middle
List other names on school records (Maiden name) _________________________________________________________________________
___________________________________________________________________________________________________________________
Address City State Zip Code
Preferred method of communicaon: (Check one) cPhone cEmail cText Cell Phone Number___________________________________
Home Phone Number_________________________________ EmaIl____________________________________________________________
Are you a U.S. Citizen? cYes cNo If No, are you a U.S. permanent resident? cYes cNo
If you are not a legal resident, what is your current visa status?_________________________________________________________________
Is English your nave language? cYes c No If No, what is your native language?___________________________________________
GENERAL INFORMATION
FEDERAL GOVERNMENT STATISTICAL INFORMATION (OPTIONAL)
Gender: cMale cFemale cUndisclosed Date of Birth __________/_________/_________
Ethnic Background: Are you Hispanic/Lano? cYes cNo
Race: cAmerican Indian or Alaska Native cAsian cBlack or African American
cNative Hawaiian or Other Pacific Islander cWhite cMulti Racial cRace Unknown
FEDERAL GOVERNMENT STATISTICAL INFORMATION (OPTIONAL)
Federal law requires that NCC collect names and corresponding social security numbers for all students aending the college. The college is
required by the Internal Revenue Code to produce a 1098-T tax form (26 U.S.C.A. Secon 6050 or Federal Register, Vol. 67, No. 2244, page
777686 (ii)) which requires the college to report the names and social security numbers of all students taking credit-bearing courses. Please
note, however, that the college will ensure the security of the student’s social security number and will not disclose it to anyone outside the
college, except as authorized by federal or state laws or applicable policies. Social Security Number _________-_________-_________
HIGH SCHOOL - GED/HiSET INFORMATION
___________________________________________________________________________________________________________________
School Name City State Zip Code
__________________________ OR __________________________
Date of Graduaon Year GED/HiSET Awarded
COLLEGES PREVIOUSLY ATTENDED DATES ATTENDED DEGREE TRANSFER CREDIT
_______________________________ ____________ _______ _________________ ________ ____________________
School Name City State
_______________________________ ____________ _______ _________________ ________ ____________________
School Name City State
VETERANS
Have you ever served in the U.S. Armed Forces? cYes cNo
Are you applying or have you applied for Survivors’ and Dependents’ of Veterans Education Assistance? cYes cNo
EMERGENCY CONTACT INFORMATION
___________________________________________________________________________________________________________________
First Last
Preferred Phone_________________________________ Relaonship to applicant________________________________________
APPLICATION CONTINUES ON BACK OF SHEET QUESTIONS? EMAIL: NASHUA@CCSNH.EDU OR CALL 603.578.8908
April 9, 2020
ACADEMIC PROGRAM
Which semester do you wish to begin your studies? cFall cSpring cSummer Year___________
Applying for:________________________________________ cAssociate Degree cCercate
cDay cEvening cFull-me cPart-me
Student Type: cFirst-Time Freshman cPrevious NCC Student cTransfer cRunning Start Parcipant
Are you applying for academic amnesty? (Prior NCC students only) cYes cNo
EDUCATIONAL GOALS
Select one of the following responses which most closely matches your reasons/goals for attending Nashua Community College.
c
Complete a certificate program cObtain an associate degree cTransfer to a 4-year college or university
cObtain or update skills cSelf-improvement/personal enjoyment cChange careers
ACADEMIC FOCUS AREA
Select one of the following Academic Focus Areas (AFA’s) you wish to pursue.
c
Arts, Humanities, Communication & Design cBusiness cIndustry & Transportation cHealth Sciences & Services
cSTEM & Advanced Manufacturing cSocial, Educational & Behavioral Sciences cHospitality & Culinary
RESIDENCE INFORMATION
cI have always lived in New Hampshire OR _______________________________________________________________________________
___________________________________________________________________________________________________________________
Month and Year Moved to New Hampshire
Previous address if residency is less than one year in New Hampshire - City, State, Zip
NEW ENGLAND REGIONAL STUDENT PROGRAM (NERSP)
The New England Regional Student Program enables a resident of a New England State to enroll in a public college or university in the six state
region at reduced rates for certain degree programs if:
• The program is not available in the home state public instuons, and/or
• The out-of-state public instuon is nearer to the student’s residence than the in-state instuon that oers a similar program.
I AM A STUDENT WHO WISHES TO BE CONSIDERED FOR NEW ENGLAND REGIONAL STUDENTS PROGRAM.
I am a resident of:____________________________________________________________________________________________________
Town or City State Academic Major
DUAL ADMISSION PROGRAM IN CONJUNCTION WITH THE UNIVERSITY SYSTEM OF NEW HAMPSHIRE
I request enrollment in the dual admissions program between Nashua Community College and (you may select more than one).
cUNH-Durham cUNH-Manchester cKeene State cPlymouth State University cGranite State College
• By doing so: I authorize both Nashua Community College and any designated schools to release an ocial copy of my transcript and any
other relevant student informaon to each other for the purposes of Dual Admission.
• I understand this request for Dual Admission and Release of Informaon in accordance with the Family Educaon Rights and Privacy
Act (FERPA) shall remain in eect at all mes when I am an acve student at either Nashua Community College or any other University
System school unless we are noed otherwise in wring.
NASHUA COMMUNITY COLLEGE 505 AMHERST ST. NASHUA, NH 03063 603.578.8908 NASHUA@CCSNH.EDU
TO BE SIGNED BY ALL APPLICANTS
The informaon provided by the applicant on this admission applicaon form shall be held condenal to the extent determined by Federal
Law and College policy. Nashua Community College reserves the right to deny admission to any applicant who, in the judgment of the College
ocials, does not qualify for admission. The College also reserves the right to require withdrawal of any student who does not sasfy the
ideals of cizenship, character or scholarship. In accordance with the terms and condions set forth in its publicaons, and if accepted to
abide by the rules and regulaons set forth in the publicaons and in the Student Handbook, I also agree that the College has permission
to use any College sponsored pictures in which any likeness appears. I have read and understand the Technical Standards outlined in the
current college catalog associated with the degree I am pursuing. I cerfy that I have read and agree with the above, and that all informaon
provided herein is true and complete.
__________________________________________________________________ ___________________________________________
Signature Date
__________________________________________________________________ ___________________________________________
Signature of Parent (if student is under 18 years) Date
SELF CERTIFICATION
c I cerfy that I have graduated or will graduate from high school or have received the equivalent of a high school diploma (e.g., accredited
alternave diploma program, HiSET or GED) by the start date of the semester for which I am applying. I understand that if I provide false
informaon about graduaon from high school or equivalent, I may be required to return any Title IV nancial aid funds I receive.
Falsicaon of records could also result in disciplinary acon from the college, including expulsion.
Transcripts may be used in course placement, and specic academic programs may require submission of high school transcripts, including
for proof of successful compleon of specic courses; therefore, students are encouraged to submit transcripts in order to be accurately
placed into college courses.
NASHUA COMMUNITY COLLEGE 505 AMHERST ST. NASHUA, NH 03063 603.578.8908 NASHUA@CCSNH.EDU
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Applicaon for Admission Please complete all items (Nashua Community College)

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Completed 26 July 2020

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