[   ] Clinton Community College 1000 Lincoln Boulevard Clinton, Iowa 52732 (563) 244-7001 [   ] Muscatine Community College 152 Colorado Street Muscatine, Iowa 52761 (563) 288-6001 [   ] Scott Community College 500 Belmont Road Bettendorf, Iowa 52722 (563) 441-4001

Toll-free 1-888-336-3907

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?

Last Name           First Name           Middle Name

Suffix  (Jr., Sr., III)

Home Address  (mailing address)

Street Address

City                                   State           Zip Code

Alternative Address  (if different mailing address)

Street

City                                   State           Zip Code

Home Phone  (     )                 Cell Phone  (     )   Work Phone  (     )                 Alternative Phone  (     )

Social Security Number

Birth Date    Month  __________    Day  __________    Year  __________

Ethnic Origin   OPTIONAL   (circle one)   1. American Indian or Alaskan Native 2. Asian or Pacific Islander 3. African American/Black, Non Hispanic 4. Hispanic 5. Caucasian/Non Hispanic     Gender       [   ]  Female     [   ]  Male

Email Address

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?   (circle one)     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. 9.  Undecided/unknown/other.

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   City   State   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.   (circle one) 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.

College Name   City   State

What is the highest degree you have earned at a college or university?   (circle one)     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

SIGNATURE _________________________________________________________________     DATE __________________     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