Middlesex Community College
Non-Credit Program
Supplemental Application
PLEASE PRINT CLEARLY USING BLUE OR BLACK INK
Full Name
Street Address Apt #
City State Zip Code
Home Phone Cell Phone
Email
Social Security Number Birth date
Emergency Contact Contact’s Phone
Do you consider yourself to be Hispanic/Latino? Yes No
What is your race? (select one or more) White Black or African American Asian
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Are you a U.S. Citizen? Yes No If no, are you a permanent resident? Yes No
Have you ever taken a credit or non-credit course at one of the CT Community Colleges? Yes No
Are you a current MXCC student? Yes No
Are you planning to utilize a payment plan for this program? (for programs over $1,000) Yes No
Are you receiving third party funding? Yes No If yes, what is the funding source?
NoIf yes, have you taken an ESL test? YesNoIs English your second language? Yes___ ___ ____ _____
An ESL test is recommended prior to enrolling if English is your second language. Call 860-343-5770 to schedule.
Education
NoGED Certification: YesCurrently attendingNo_High School Graduate: Yes____ ___ _____ ____ ____
Year of Graduation: Name of High School: ________________________________
College:
If yes, registration #NoAre you a Nurse Aide whose certification has expired? Yes____ ____ ______________
I certify that the information provided above is, to the best of my knowledge, true and correct, and I consent to
the disclosure of this and program participation information between Middlesex Community College,
Connecticut State Colleges and Universities and state and federal Departments of Labor for the purposes of
maintaining accurate student records and to monitor grant performance.
Signature:
Program:
Banner ID: Date:
Completed applications should be submitted along with all required materials to:
Middlesex Community College
Office of Enrollment Services
100 Training Hill Road
Middletown, CT 06457
Rev. 6/2017
