Application for Admission

Application for Admission
Sullivan County Community College

PERSONAL INFORMATION

Date of Birth

Gender

First Name

Middle

Last Name

If you have records under a another name, please indicate:

Former Last

Former First

Permanent Mailing Address

City	State	Zip	Country

Home Phone

Cell Phone

Email Address

HIGH SCHOOL INFORMATION

I have graduated or will graduate from high school
I have completed the GED program

Year

High School Name

Address

City	State	Zip	Country

COLLEGE INFORMATION

I am applying as a:

First time student

Returning student

Transfer student

List colleges attended previously
College 1 Name	Degree Earned
College 2 Name	Degree Earned

Have you ever taken courses at Sullivan?

Yes

Semester and Year you wish to enroll?

Enrollment Status

Program of Study

RESIDENCY INFORMATION

Are you a US Citizen?	Yes	No
Are you a New York State Resident?	Yes	No	If yes, County of Residence

If applicable, please indicate name and address of parent or guardian with whom you reside:

Name

Address

City	State	Zip	Country

Phone

INTERNATIONAL STUDENTS

Country of Birth

Country of Citizenship

Are you a permanent resident of the U.S.?	Yes No
If Yes, provide Alien Registration Number

If you are NOT a permanent resident, indicate your visa type

Visa Expiration Date /

Indicate the number of years you have been in the U.S.

Date latest Test of English as a Foreign Language(TOEFL) was taken

BACKGROUND QUESTIONS

Have you ever been convicted of a felony?

Yes No

Have you ever been dismissed from a college for disciplinary reasons?

Yes No

If yes, reason dismissed

OPTIONAL QUESTIONS

Race/Ethnic Background

How did you find out about Sullivan County Community College?