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 form may be subject to disciplinary action and possible dismissal from Clovis Community College.
Student’s Signature:
Date:
EDUCATION INFORMATION
Name of High School:
City & State:
Expected Graduation Date:
Month/Year
Citizenship Status:
U.S. Citizen
Permanent Resident
Non-U.S. Citizen: Please list country of citizenship:
________________________
If you have a current visa, please list visa type and expiration date:
Dependent of Active-Duty Military?
Dates of residence in New Mexico: From
To
R
A
C
E
Please select 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
Full Legal Name
Current Mailing Address
City
Email Address
Preferred Phone Numbers:
Emergency Contact
Name
Address (if different from above)
Relationship
Phone Number
Semester you plan to enroll:
Year: 20____
PERSONAL INFORMATION All student information is kept confidenti
al
Social Security Number
Date of Birth
(MM/DD/YYYY)
Male
Female
Street Address City, State, Zip
State Zip
Return application to:
Admissions and Records Office
417 Schepps Blvd.
Clovis, NM 88101-8381
(575) 769-4025
Fax: (575) 769-4027
admissions@clovis.edu
High School Admission Application
Please type or print legibly in ink. Answer all questions. Sign and date the application.
Fall
Spring
Summer
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, CCC Room 134, 575-769-4144 and Mrs. Regina Dart, Director of Human Resource Services, CCC 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.
Rev. 0
7/7/20 KS
C
Last Name
First Name
Middle Name (Optional)
Cell
Home
Other
Cell
Home
Other
RESIDENCY INFORMATION (REQUIRED)
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?
If no, which state? ____________
Yes
Yes
Yes
No
No
No
No
High School ID/STARS ID:
click to sign
signature
click to edit
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