Eastern Iowa Community College District/Palmer College of Chiropractic Application for Joint Admissions   Complete all information and return this application to the Palmer College Director of Admissions. Please type or print clearly. Please press firmly.   PERSONAL DATA Social Security # ________/_______/_________   Name ____________________________________________________________________________________   Last First Middle Other name that may appear on Supporting documents Current Mailing Address ____________________________________________________________________ Number and Street _____________________________________________________________ Telephone (   )________________   City                                                 State                     Zip Code   Permanent Mailing Address __________________________________________________________________ Number and Street _____________________________________________________________ Telephone (   )________________   City                                                 State                     Zip Code   U.S. Citizen or Resident ____ Yes   ____ No         If No, country of citizenship ________________________   ADMISSION INFORMATION   High School Name _________________________________________________________________________   High School Address _______________________________________________________________________   Graduation Date ____________     High School graduation by: ____ Diploma   ____ Equivalency Certificate   Anticipated date of entry at Palmer College of Chiropractic ______________________________________   Other Colleges attended prior to anticipated enrollment at Palmer College of Chiropractic ____________ _________________________________________________________________________________________   Intended Scott Community College Program of Study   ___________ Pre-Doctor of Chiropractic _________________________________________________________________________________________   I authorize Eastern Iowa Community College District and Palmer College of Chiropractic to release confidential education record information (including grade reports and/or transcripts) to each other.   I certify that the foregoing information is true and complete to the best of my knowledge and realize that failure to provide official transcripts and other required information may result in the cancellation of admission or registration.   _____________________________________________________ ________________________________     Student Signature (required)     Date _____________________________________________________ ________________________________     Palmer College Director of Admissions     Date   For EICCD office use only: Date Received __________ Term Applied   __________ Bursur              __________   Please return all copies to: Palmer College of Chiropractic Attention: Admissions 1000 Brady Street Davenport, Iowa 52803   For Palmer office use only: Term       __________ Fee Paid __________ Status     __________