Application for Admission Colby Community College Dental Hygienist Program
Please print
(Last) (First) (Middle) (Maiden)
Home Address________________________________________________________________________________
(Street) (City) (State) (Zip)
Active E-mail address__________________________________________________________________________
Birthdate_________________________________________________________ Sex: Male_____ Female _____
(Month) (Day) (Year)
High School Graduate Of_______________________________________________________________________
(School or GED) (State) (Year)
Social Security Number________________________________ Marital Status: Married ______ Single _____
If you choose not to use your Social Security number, a number will be assigned for identification purposes. Financial
Aid cannot be processed without Social Security number.
U.S. Citizen? Yes _____ No _____ If not, Visa Type _____
Permanent Resident___________________________________________________________________________
(County) (State) (Zip)
Circle One: Mr. Mrs. Ms. Mr & Mrs.
Ethnic/Racial Status (required for federal and state accounting purposes only):
Asian American_____ Black/American_____ Mexican/American_____
American Indian_____ Hispanic/American_____ White_____
Have You Earned Previous College Credit? Yes_____ No_____ Hours of Credit______________
College (s) Where Credit Was Earned____________________________________________________________
Did either of your parents graduate from a 4-year institution? Yes_____ No_____
Have You Ever Been Convicted of a Felony? Yes_____ No_____ If yes, please give a brief explanation
(What, where, when): __________________________________________________________________________
Attach your $100.00 non-refundable check/money order payable to Colby Community College to this form. Include this
application in your portfolio along with the other necessary requirements listed on your “checklist”.
I certify that the information given is correct and complete. I understand that submission of false information is grounds for
denial of admission, re-enrollment or immediate suspension if enrolled. If accepted as a student at Colby Community College,
I agree to abide by the rules and regulations of the college regarding conduct, financial and other obligations. By signing this
statement, I also hereby authorize the release of all my college, vocational and/or high school transcripts and other pertinent
records to Colby Community College.
Signature: ________________________________________ Date: ___________________________
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