[   ] 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
  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)
  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
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.

  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:
   image An equal opportunity institution