1101 Sherman Drive, Utica, NY 13501
Phone (315) 792-5336
Fax (315) 792-5698
__________________________________________________
Student Signature Date
__________________________________________________
Faculty Signature Date
Print Name _____________________________________________________________
(Last) (First) (M.I.)
Student M# _________________________ Social Security # _____________________
Semester ___________________________Major ______________________________
Address _______________________________________________________________
Street City State Zip Code
County _____________________________ Phone _____________________________
Email ______________________________ Date of Birth: ________________________
Have you previously attended MVCC? ☐ ☐ Former Name ___________________
Yes No (if applicable)
If yes, year: ______________ Sex:
Native Hawaiian / Pacific Islander
American Indian / Alaskan Native
Transfer to another SUNY college after earning a degree.
Transfer to a non-SUNY college after earning a degree.
Transfer to a SUNY college without earning a degree.
Transfer to a non-SUNY college without earning a degree.
Earn a degree/certificate and seek employment, rather than pursue
further post secondary education.
Learn new skills or upgrade existing skills without earning a degree.
Seek enrichment, rather than to pursue a degree / certificate.
Obtain a Certificate of General Education Development (GED)
through the accumulation of college credits.
Uncertain, student has not yet determined his/her goal at this time.
IF YOU DESCRIBE YOURSELF AS A PERSON WITH A DISABILITY PLEASE CONTACT
THE DISABILITY SERVICES OFFICE AT 792-5413.
DISCLOSURE OF SOCIAL SECURITY NUMBER IS VOLUNTARY AND IS USED FOR
STUDENT IDENTIFICATION. AUTHORITY TO SOLICIT THE SOCIAL SECURITY NUMBER
HAS BEEN ESTABLISHED UNDER SECTION 3545 OF THE EDUCATIONAL LAW OF THE
STATE OF NEW YORK.
ETHNIC IDENTITY (Please check all that apply)
!
PRIMARY EDUCATIONAL OBJECTIVE (Please check one)
Please check here if your address has changed.
CRN COURSE # COURSE TITLE CREDIT HOURS COMMENTS
NOTE: PLEASE MAKE SURE YOU KNOW THE EFFECTS OF THESE COURSES ON YOUR PROGRAM
