INTERNATIONAL STUDENT APPLICATION FOR ADMISSION CLINTON, MUSCATINE AND SCOTT COMMUNITY COLLEGES

[   ] 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?   If yes, what year did you first attend? ________________   Name while enrolled:   Social Security Number   Last Name                                                                         First Name                                                                   Middle Name   Do you intend to complete a degree, diploma or certificate program at this college?         [   ] Yes   [   ] No               (Only degree seeking students are eligible for federal financial aid.)   What is your main purpose for attending this college?   (circle one)   A. Prepare to enter the job market B. Improve skills for present job C. Prepare to change careers D. Meet certification/licensure requirements      (other than for initial job entry) E. Transfer to another college/university F. Explore courses to decide on a career G. Self improvement/Improve basic skills H. Personal interest I.   Undecided/Unknown   Date of birth     (Mo.,   Day,   Yr.)     Gender     [   ] Female   [   ] Male     Are you an Iowa resident?         [   ] Yes   [   ] No   Length of Iowa residency   _________ Yr.   _________ Month   Please indicate your racial/ethnic origin   (optional).   This information will remain confidential. Circle only one category:       1.  African American, Non-Hispanic           4.  Hispanic or Latino       2.  Asian or Pacific Islander                        5.  Caucasian/Non-Hispanic       3.  American Indian or Alaskan Native       6.  International Student   Are you a citizen of the United States?   [   ] Yes   [   ] No         If no, what is your current visa status? ______________________________   If no, are you:   [   ] U.S. Permanent Resident     [   ] Refugee     [   ] Asylee     [   ] International Student   (1-20 Required)   Country of Birth                                                                                     Country of Citizenship   E-mail Address   List a permanent address where mail will always reach you if different from current address.   Address:   (Number and Street)   City                                                                                           State                                                                          Zip Code   Phone (area code)   List a current or local address.   Address:   (Number and Street)   City                                                                                           State                                                                          Zip Code   Phone (area code)                                                                             Work Phone (area code and extension)   Which semester do you plan to begin?   [   ] Fall (August-December)   [   ] Winter (January)   [   ] Spring (January-May)   [   ] Summer (May-July)   Which year? ______   Area of Concentration   (Program of study)

EDUCATIONAL BACKGROUND

Name of high school from which you were (or will be) graduated including city, state, month and year. Non-graduates, list last school   attended including name of school, city, state:

High School Name or GED City, State If Applicable, month/year of Graduation Student's Name While Enrolled

Please select the category and sub-category (if applicable) that best describes your educational background at the time you enter   classes at this college?     [   ]   1.  High School Equivalency (GED) Received:     [   ]   2.  Currently in High School     [   ]   3.  Not a High School Graduate     [   ]   4.  High School Graduate     [   ]   5.  College Course Work/Degree

What is the highest award (if any) you have earned at a college or university?     [   ]   Certificate     [   ]   Diploma     [   ]   AA/AS/AAS Degree     [   ]   BA/BS Degree     [   ]   Graduate Degree     [   ]   Other

List all colleges you have or are currently attending. If you have never attended a college, write NONE.

College Name City, State From (mo./yr.) To (mo./yr.) Credits Earned Type of Degree Earned Student's Name While Enrolled

Has either of your parents received a four-year college degree?   [   ] Yes   [   ] No

Is English your native language?   (optional)   [   ] Yes   [   ] No

Applicants: make sure official high school, Ged and all college transcripts are sent to the college admissions office. If you are not a united states citizen, you must enclose a copy of your passport, visa, I-94 or green card. This is necessary for billing and admittance to the college. No application fee required.

CERTIFICATION OF INFORMATION

I certify that all of the information I have supplied in this application and any supporting documents is true, accurate and complete.   SIGNATURE _________________________________________________________________     DATE __________________

The Eastern Iowa Community College District 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.

Visit our website:    www.eicc.edu         An equal opportunity institution