518 West Locust St.           Davenport, Iowa 52803 Application for Joint Admission EICCD ~ St. Ambrose University           (800)383-2627 ~ (563)333-6300           admit@sau.edu ~ www.sau.edu/     Student Information To be completed by applicant. Use typewriter or print legibly in ink.   Name______________________________________________________________________________________________________________                                     Last                                         First                                         Middle                                         Maiden Other name that may appear on supporting documents ____________________________________________________________________ Current mailing address ______________________________________________________________________________________________                                                                                                Number                                               Street                                           ______________________________________________________________________________________________                                                                                                 City                                                      State                           Zip Current phone _________________________________________ Permanent phone _________________________________________ Email address ______________________________________________________________________________________________________ United States Social Security number                     United States citizen or resident   Yes   No     If no, country of present citizenship _____________________________________       Admission Information   High school name ____________________________________________   City, State ____________________________________________ High school graduation date ________________________     High school completion by   Diploma   Equivalency certificate Anticipated date of entry at St. Ambrose University ____________________(Semester)     _________(Year) Have you previously enrolled at St. Ambrose University?   Yes   No     If Yes, during what semester and year? ____________ Are you seeking a degree from St. Ambrose?   Yes     If yes, possible date of graduation ___________________________________ Other colleges attended prior to anticipated enrollment at St. Ambrose University ____________________________________________ __________________________________________________________________________________________________________________ Intended program of study at EICCD ______________________________       Intended SAU major _______________________________       Financial Aid   I understand that I must complete an AA (Associate in Arts) Degree at CCC, MCC or SCC. I understand I must maintain a minimum 2.0 cumulative GPA based on all transferable course work from all colleges attended. I understand I must meet the same criteria (e.g., GPA, course requirements, and prerequisites) for admission to competitive programs as continuing St. Ambrose University students. I authorize EICCD to release confidential education record information (including grade reports and/or transcripts) to St. Ambrose University. 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 EICCD Official (required) Date