Clinton Community College
1000 Lincoln Boulevard
Clinton, Iowa 52732
Muscatine Community College
152 Colorado Street
Muscatine, Iowa 52761
Scott Community College
500 Belmont Road
Bettendorf, Iowa 52722
CLEARLY TYPE OR PRINT ANSWERS TO ALL ITEMS AND RETURN TO THE ABOVE ADDRESS.
Have you previously applied/been enrolled in college credit classes at... [ ] Clinton [ ] Muscatine [ ] Scott Community Colleges?
Suffix (Jr., Sr., III)
Home Address (mailing address)
Alternative Address (if different mailing address)
Home Phone ( )
Cell Phone ( )
Work Phone ( )
Alternative Phone ( )
Social Security Number
1. American Indian or Alaskan Native
2. Asian or Pacific Islander
3. African American/Black, Non Hispanic
5. Caucasian/Non Hispanic
Gender [ ] Female [ ] Male
Please list other names you have used that might appear on documents or incoming transcripts.
Which term do you plan to begin?
[ ] Fall (Aug - Dec) [ ] Winter (January) [ ] Spring (Jan - May) [ ] Summer (May - July) Which year?
Program of study or area of concentration
Which campus do you plan to attend?
[ ] Clinton Community Colleges [ ] Muscatine Community Colleges [ ] Scott Community Colleges
What is your purpose for attending this college?
1. Transfer to another college/university.
2. Prepare to enter job market.
3. Explore courses to decide career.
4. Self-improvement/improve basic skills.
5. Take courses for personal interest.
6. Improve skills for present Job.
7. Prepare to change careers.
8. Meet certification/licensure requirements.
Are you a citizen of the United States?
[ ] Yes [ ] No
If No, are you
[ ] US Permanent/Temporary Resident
[ ] International Student (I -20 Required)
Country of Birth
Country of Citizenship
Is English your native language? [ ] Yes [ ] No (if No, indicate native language)
Are you an Iowa resident? [ ] Yes [ ] No
If Yes, how long have you lived in Iowa?
_________ Year _________ Month
Name of high school or GED center from which you were (or will be) graduated.
High School Name
If applicable, year of graduation
Indicate High School/GED status that best describes your educational background at the time you enter classes at this college.
1. Received high school diploma
2. Received GED
3. Non-high school graduate
4. Still in high school
Have you attended another college or university? [ ] Yes [ ] No
List all colleges and universities that you have attended.
What is the highest degree you have earned at a college or university?
1. Two-year degree: Associate in Arts, Associate in Science or Associate in Applied Science
2. Four-year degree: Bachelor in Arts or Bachelor in Science
3. Graduate degree
4. No college degree
Has either of your parents received a four-year college degree? [ ] Yes [ ] No
Do you intend to complete a degree, diploma or certificate program at this college? [ ] Yes [ ] No
The endorses the principle of equal educational opportunities for all people regardless of race, color, creed, marital status, national origin, sex, sexual orientation, religion, ancestry, age, or non-job related handicap or disability in the educational programs or activities it operates. Persons having inquiries concerning the district's accommodation for or compliance with Title VI, Title IX, Section 504, the Americans with Disabilities Act and the Age Discrimination Act may contact: Affirmative Action Officer, 306 W. River Drive, Davenport, IA 52801, 563- 336-3300.
Dean of Student Development, Clinton Community College, 1000 Lincoln Boulevard, Clinton, Iowa 52732, 563-244-7001; Dean of Student Development, Muscatine Community College, 152 Colorado Street, Muscatine, Iowa 52761, 563-288-6001; Dean of Student Development, Scott Community College, 500 Belmont Road, Bettendorf, Iowa 52722, 563- 441-4001.
An equal opportunity institution
Updated DECEMBER 2004