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Social Security Number:________/______/__________ SAS ID#_________________ Date of Birth:______/______/______
Full Name: _______________________________________________________________________ Any Previous Last Name(s): ____________________________________
Last First Middle
Preferred First Name:
Mailing Address:
Street Apt.
City State Zip
Email Address ______________________________________________________Primary Phone #: ______________________ ALT #: ________________________________
I wish to receive non emergency text messages from NECC. (Optional). Cell phone # ________________________________________________________________
[Consent is revoked by notifying Enrollment Services].
Northern Essex Community College has an open admission policy and accepts students on a rst-come, rst-served basis for most programs. Some
programs have special admission criteria and/or limited enrollment. Please check the college website at for details on these
special programs. Early College students must seek High School approval.
Demographic Information - Optional
We ask the following questions to help the College best serve our students and our region. Information provided will not be used in a discriminatory manner.
Your response to these questions makes it possible for us to apply for resources to help support our students.
Race/Ethnicity: Please answer both a. and b.
a. Ethnicity: Are you of Hispanic or Latino origin?
Yes No Gender: Male Female _____________________________________________________
b. Race: Choose one or more from the list below.
African-American/Black Asian American Indian/ Alaskan Native Cape Verdean Native Hawaiian/Pacic Islander White/Caucasian
c. Did your parent(s) graduate from college with a bachelor’s degree? Mother:
Yes No Father: Yes No
For oce use only:
generated student ID _______________________
Optional. Required if seeking tax credit.
Month Day Year
High School Education
High School Name:______________________________________________________ City: ______________________________________________ State:_____________________
Year of Graduation ______________________
Educational Objectives
Please select at least one Early College major.
If you are unsure about your selection and would like further guidance please check here
What is your overall goal at NECC?
Earn a degree or certicate
Transfer to a 4-year institution
If transfer, are you interested in:
Mass Transfer: Transfer to MA public institution with tuition benet
Bachelors Degrees at NECC: NECC graduates can earn a bachelor’s degree on campus through one of our 4 year partnerships.
Enter workforce upon graduation
Liberal Arts
Criminal Justice
Individual (unsure of degree
goals at this time)
Armative Action and Equal Opportunity Policy: Northern Essex Community College is an armative action/equal opportunity college and does not discriminate on
the basis of race, color, national origin, sex, disability, religion, age, veteran status, genetic information, gender identity or sexual orientation in its programs and activities
as required by Title IX of the Educational Amendments of 1972, the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Title VII of the Civil
Rights Act of 1964, and other applicable statutes and college policies. The College prohibits sexual harassment, including sexual violence. Inquiries or complaints concerning
discrimination, harassment, retaliation or sexual violence shall be referred to the College’s Armative Action and/or Title IX Coordinator, the Massachusetts Commission
Against Discrimination, the Equal Employment Opportunities Commission or the United States Department of Education’s Oce for Civil Rights.
All inquiries concerning application of the above should be directed to the College’s Armative Action/Section 504 Compliance Ocer: Justine Caron, Director
of Human Resources, Section 504/ADA Compliance; Title IX; Armative Action; Northern Essex Community College, 100 Elliott Street, B-219, Haverhill, MA 01830; Phone:
978-556-3956; Email:
Source__________________________ Contact___________________________ Sta______________________________ Date______________________________
Applicant Signature
I certify that all the information submitted on this application is true.
Signature of Applicant: _________________________________________________________________ Date: ___________________________________________
Signature of Parent: ____________________________________________________________________ Date: ___________________________________________
Only needed if Applicant is under 18 years of age
Questions? Please email us at or call us at 978-659-1235.
Emergency Contact Information
Name: _______________________________________________________________________________ Relationship: ______________________________________________
First Last
Address: _________________________________________________________________________________________________________________________________________________
Street Apt.
City State Zip
Telephone: ______________________________________________________________________________________________ Email:___________________________________________________________
Parent/Guardian Information
I/we give permission for my/our child, named above, to attend college-level classes at Northern Essex Community College, and I/we will be responsible for paying for
books for courses oered on the NECC campus. I authorize Northern Essex Community College to release educational records to the High School.
Name (Please print)__________________________________________________Parent/Guardian Signature ______________________________________Date:__________________
School Ocial Information
I certify that the student has a 2.5 cumulative GPA (on a 4.0 scale) or is otherwise recommended (include a letter of support if GPA is under 2.5) and that the listed
course satises his/her high school graduation requirement and will be posted to the students transcript. Does this student qualify and or participate in a Free/
Reduced Lunch program? Yes No
Certifying HS Ocial (Please print) Title
Certifying HS Ocial Signature Date
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FAMILY Educational Rights and Privacy Act (FERPA)
Authorization to Release Information to a Third Party
Student Name: ________________________________________________________________ NECC ID no.: __________ _____________________ ___ __
The Family Educational Rights and Privacy Act (FERPA) prohibits an institution of higher education from releasing most student record information to
any requesting third party, absent the student’s prior written consent. Failure of the College to comply with FERPA may result in a violation of federal
law and jeopardize the College’s federal funding. I authorize Northern Essex Community College to release my educational record information to:
Name of Individual: Relationship:
_____________________________________________________________ ______________________________________________________________
_ ___________ ________ ________ ________ ________ ________ _________ ______________________________________________________________
_____________________________________________________________ ______________________________________________________________
_ __ ____ _________ ________ ________ ________ ________ ________ _____ ______________________________________________________________
I authorize NECC to release the following information (check all that apply):
Student Accounts: Includes tuition and fee balance, nancial holds, mailing and billing address, payment plans, accounting statements, collections
information, and debt information.
Admissions: Includes the date of application, program selected, documents received, documents pending, date of admission, admissions status,
and condition of admission.
Registration: Includes current enrollment, date of enrollment activity, enrollment status, residency status, semesters attended, and mailing address
Academic Records: Includes courses taken, grades received, GPA, academic progress, honors, transfer credit, and degrees earned.
Financial Aid: Includes all general nancial aid information.
CODE WORD: __________________________________ (The code word is used to validate your authorized individuals. Please provide your code word to
the authorized individuals listed above).
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