Name (Last, First, MI): _______________________________________________________________________________
Address: ___________________________________________________________________________________________
City: ______________________________________________________ State:_____ Zip: ________________________
Phone Number: ________________________ D.O.B. (mm/dd/yyyy): ____________ Gender: _____________________
Email: ________________________________________Race: _______________Ethnicity: _______________________
Name of High School: _________________________________________ High School G.P.A. ____________________
High School City: __________________________ State: _____ Graduation Date (mm/yyyy): _____________________
1. Are you a US citizen, national, refugee, or lawful US permanent resident? □ Yes □ No
2. Have you completed the Free Application for Federal Student Aid (FAFSA)? □ Yes □ No
3. Have you taken the NVCC Accuplacer Placement Test? □ Yes □ No
4. How did you hear about the NVCC STEM NViSION Program (If referred by a current member, please indicate his/her name)?
___________________________________________________________________________________________________
5. What major are you interested in pursuing? _____________________________________________________________
6. What is your ultimate career goal? ____________________________________________________________________
7. Are you planning on being a full-time student (note: a commitment to full-time enrollment is a condition of acceptance into the
NViSION program)? □ Yes □ No
8. Do you currently work? □ Yes □ No If yes, about how many hours per week do you work? _____________________
9. Do you plan to work while attending NVCC? □ Yes □ No
If yes, where and about how many hours per week? ________________________________________________
10. What is your estimated family income: □ $0-$31,000 □ $32,000-$39,000 □ $40,000-$48,000 □ $49,000+
11. Which of the following science and math courses have you taken in high school?
□ Biology □ Algebra I □ Statistics □ Geometry
□ Chemistry □ Algebra II □ Precalculus
□ Physics □ Trigonometry □ Calculus
□ Other STEM courses (e.g. engineering) Please specify______________________________________________
12. List any of the classes from question 11 that were taken at the honors or advanced placement (AP) level.
____________________________________________________________________________________________________
13. List any other awards and/or activities (e.g. clubs, volunteer work, sports teams) you have been involved in that you feel
would be important for the selection committee to consider.
____________________________________________________________________________________________________
14. Are you a current NVCC student? □ Yes □ No If no, have you applied to NVCC? □ Yes □ No
If you are not a current student and have not applied to NVCC, please do so at www.nv.edu/apply
I, _________________________________,(print name) certify that all information provided in this application package is
complete and accurate to the best of my knowledge. NVCC has the sole responsibility for selecting students based on criteria as
set forth in the program’s descriptive brochure. I acknowledge that all decisions of the NViSION Program are final.
Falsification of any information will result in rejection and/or removal from the NViSION program.
___________________________________________(Applicant Signature) ______________________(Date)
Naugatuck Valley STEM Inclusive Opportunity Network
(NViSION)
Program Application
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