Personal Information
International Student Supplemental Application
Please complete all information.
Please select the location you plan to attend
Columbus, Nebraska
Grand Island, Nebraska
Hastings, Nebraska Kearney, Nebraska
Type your name as it appears or will appear on your passport. (Provide a copy of your Passport personal information page)
Surname / Primary Name / Last Name as appears on passport
Given / First as appears on passport MIDDLE
Gender Male Female
(please check one)
City of Birth Country of Birth
Country of Citizenship Date of Birth MM/DD/YYYY
Do you plan to bring dependents (spouse or children) with you to CCC? YES NO
If yes, on a separate sheet of paper, submit the following information about each dependent with this application. An I-20 is needed
for each dependent. Family housing not available.
1.
Full names as shown on passport
2.
Relationship to you
3.
Gender
4.
Date of birth
5.
Country of birth
6.
Country of citizenship
Permanent Address in Your Home Country Mailing Address (to receive official CCC correspondence)
Address
Address
Address 2
Address 2
City
City
State/Province
State/Province
Country
Postal Code
Country Postal Code
Telephone Number (Include Country Code and City Code) Fax Number (Include Country and City Code)
Cell Phone Number (Include Country Code and City Code) Email Address
Revised 6.15.2020
Contact Person in the United States (if available)
Name (First and Last)
Telephone Number
Address
Email Address
Address 2
State/Province
Postal Code
Telephone Number
Visa & Passport Information (must be completed)
If you are currently in the U.S. on an F-1 student visa, please list
the name of the institution that has issued your I-20:
Visa Issue Date:
Visa Number (red with 8 letters and/or numbers):
Passport Number:
Admission Information
Intended Major
Beginning Level of Study Attendance Beginning: (Summer start terms are not available for F1 Visa Students)
Freshman Fall (August) Year:
Transfer Student Spring (January) Year:
Is this the first time you have applied for CCC admission? YES NO
If no, when did you seek admission?
Semester Year CCC Student I.D. Number
Have you ever enrolled and/or withdrawn from classes at CCC? YES NO
Semester Year
Proficiency in the English Language (REQUIRED): Submitting official SAT, ACT or MAP scores will waive TOEFL
requirement. All SAT, ACT, and/or MAP scores must prove English and Math college readiness. Please request
official TOEFL, ACT, SAT, or MAP scores be sent directly to the office of Admissions. Score reports from students
will not be accepted as official.
TOEFL Test Score: TOEFL Test Date Taken:
TOEFL Type: Paper/pencil
Internet based test
Computer based t
est
Educational Background
Applicants must complete this section thoroughly and accurately. Providing inaccurate or incomplete information may
result in delay or denial of this application and dismissal from CCC.
You must submit originals or certified copies of original transcripts for all Educational Background areas. Copies must be
certified with an official seal from the school or certified by a public official authorized to verify these documents, such as
the Ministry of Education, along with an English translation.
List in chronological order all high/secondary schools attended. Please use an additional sheet of paper if
necessary.
High/Secondary School Name
Location (City and
Country)
From
MM/YYYY
To
MM/YYYY
Highest
Degree/Certificate
Please indicate your current educational status:
I am currently attending
I last attended
Have you ever been academically suspended or dismissed from any college or university? Yes No
If YES, please list the name of the school:
School Name Date
Is there anything you would like to share with us? (Optional)
Declaration of Truth
I certify that the information on this application is complete, accurate, and true; and agree to abide by the
policies and regulation of Central Community College. I understand that any information given falsely or
withheld will affect the decision on my application and may make me ineligible for admission and or
enrollment.
Applicants signature:
Name Date
click to sign
signature
click to edit
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