Declaration of Eligibility for In-State or NEBHE Tuition Rate updated ...
Declaration of Eligibility for In-State or NEBHE Tuition Rate updated ...
Declaration of Eligibility for In-State or NEBHE Tuition Rate updated ...
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New Students:N<strong>or</strong>walk Community CollegeApplication <strong>f<strong>or</strong></strong> AdmissionPlease Check One: o New Student o Re-Admit Student*An individual who has never attended N<strong>or</strong>walk Community College and wishes to enroll in a Degree, Certificate <strong>or</strong> non-degree program,please follow items 1-6 below.1. Complete all pages <strong>of</strong> this application and attach a copy <strong>of</strong> the completed immunization <strong>f<strong>or</strong></strong>m and high school diploma/transcripts.2. Return this completed <strong>f<strong>or</strong></strong>m and a non-refundable $20.00 application fee to the NCC Business Office, Room 103 - East Campus,188Richards Avenue, N<strong>or</strong>walk, CT 06854-1655. Please make checks payable to: NCC. Other methods <strong>of</strong> payment are: cash, money <strong>or</strong>der,MasterCard, Visa, <strong>or</strong> Discover. The application fee is waived if you have previously applied to another Connecticut Community College.An acceptance letter with your Student I. D. number will be sent to you via street address <strong>or</strong> email.3. Use your NCC-ID Number to schedule a placement test. From NCC’s web page, www.ncc.commnet.edu, scroll over Admissions andclick on “Schedule a Placement Test.” All new students are required to take a Placement Test pri<strong>or</strong> to enrolling at NCC.YOU MAY BE EXEMPT IF:(a) You have completed college level English and/<strong>or</strong> college level mathematics; <strong>or</strong>(b) Your SAT <strong>or</strong> ACT sc<strong>or</strong>es meet certain minimums. Check the Placement Test page <strong>of</strong> the NCC web site <strong>f<strong>or</strong></strong> exemptions.4. If you are applying to a degree <strong>or</strong> certificate program <strong>or</strong> applying <strong>f<strong>or</strong></strong> financial aid, you must have pro<strong>of</strong> <strong>of</strong> high school graduation <strong>or</strong>GED results sent to the Admissions Office.5. All degree/certificate seeking and full time students b<strong>or</strong>n after 1956 must submit pro<strong>of</strong> <strong>of</strong> immunizations including 2 doses each <strong>of</strong>measles, mumps, rubella, and varicella.6. Contact the Counseling Center at (203) 857-7033, <strong>f<strong>or</strong></strong> advising in<strong>f<strong>or</strong></strong>mation <strong>or</strong> if seeking advanced standing based upon credit transferredfrom other colleges, CLEP examination credit <strong>or</strong> experiential learning credit. Official transcripts from other colleges should besent to the Admissions Office. If you wish to have pri<strong>or</strong> college credits transferred, submit a “Transcript Evaluation Request” <strong>f<strong>or</strong></strong>mto the NCC Counseling Center.* Re-Admit Students:F<strong>or</strong>mer NCC students who have not registered <strong>f<strong>or</strong></strong> two <strong>or</strong> m<strong>or</strong>e consecutive years must apply <strong>f<strong>or</strong></strong> re-admission. There is no application fee <strong>f<strong>or</strong></strong>re-admit students. Please follow items 1-5 if you wish to enroll in a degree/certificate program <strong>or</strong> as a non-degree student.If you are re-admitting under a different name: You must submit a legal document (such as a marriage certificate) <strong>of</strong> the new name.1. Complete all pages <strong>of</strong> this application. Attach immunization in<strong>f<strong>or</strong></strong>mation if necessary.2. Return completed application to the Admission’s Office, Room 106 East campus, 188 Richards Avenue, N<strong>or</strong>walk, CT 06854-1655.3. If you will be pursuing a degree <strong>or</strong> certificate, have pro<strong>of</strong> <strong>of</strong> high school graduation <strong>or</strong> GED results sent to the Rec<strong>or</strong>ds Officeunless previously submitted.4. Contact the Counseling Center at (203) 857-7033 to schedule an advising appointment.5. The Fresh Start Option gives the readmitting student who has a GPA below 2.0 an opp<strong>or</strong>tunity to start again without the burden<strong>of</strong> a po<strong>or</strong> academic hist<strong>or</strong>y. Contact the Rec<strong>or</strong>ds Office <strong>f<strong>or</strong></strong> m<strong>or</strong>e in<strong>f<strong>or</strong></strong>mation.*Upon re-admission, students will be subject to the curriculum requirements in existence at the time <strong>of</strong> their re-admission.Students with DisabilitiesF<strong>or</strong> service <strong>or</strong> in<strong>f<strong>or</strong></strong>mation regarding disabilities please contact the Co<strong>or</strong>dinat<strong>or</strong> <strong>of</strong> Disability Services at (203) 857- 7192. If you are unable toutilize a staircase please visit the Disability Services webpage on the NCC website to plan <strong>f<strong>or</strong></strong> Emergency Evacuations.N<strong>or</strong>walk Community College • 188 Richards Avenue • N<strong>or</strong>walk, CT 06854 • (203) 857-7060admissions@ncc.commnet.edurev 7/2011
N<strong>or</strong>walk Community College188 Richards Avenue, N<strong>or</strong>walk, CT 06854 • (203) 857-7060F<strong>or</strong> Office use onlyBANNER@Date______________________Received _____________ Entered _____________________Entered by _________________________________________Admit Type _____________ Student Type ________________Ability to Benefit met _____ Yes _____ NoApplication Fee paid _____ Yes _____ NoCash ____ Check #____________ Waived ______________Credit Card ______________ Deferred __________________Applicant’s Legal NameAPPLICATION FOR ADMISSION(Last) (First) (Middle)F<strong>or</strong>mer Last Name(s) - - / /(Social Security Number) (Date <strong>of</strong> Birth) (circle one)(Social Security Number is requested <strong>f<strong>or</strong></strong> purposes <strong>of</strong> financial aid, federal income tax benefits, the provision <strong>of</strong> some College services, accuracy <strong>of</strong> studentrec<strong>or</strong>ds and other business purposes.)Mailing AddressStreet City <strong>State</strong> ZipPermanent Address(If different) Street City <strong>State</strong> ZipTelephoneHome W<strong>or</strong>k CellE-mailGender: M / F(used <strong>f<strong>or</strong></strong> c<strong>or</strong>respondence from the College)Have you ever attended this college? Yes No If yes, when? ________________________________________________Have you previously attended a CT Community College? Yes No If yes, where?________________________________F<strong>or</strong> which semester are you applying? Fall (Sept-Dec) Spring (Jan-May) Winter (Dec-Jan) Summer (Jun-Jul) Year____CitizenshipAre you a United <strong>State</strong>s citizen? Yes No If no, are you a Permanent Resident? (Green Card holder) Yes NoETHNICITY/ RACEPlease provide the following ethnicity and race data. This in<strong>f<strong>or</strong></strong>mation is requested on a Voluntary basis by the U.S. Department <strong>of</strong> Education,National Center <strong>f<strong>or</strong></strong> Education Statistics. Your answer will not affect admission to <strong>or</strong> registration in the college.Do you consider yourself to be Hispanic/Latino? Yes NoWhat is your race? Select one <strong>or</strong> m<strong>or</strong>e: White(10) Black <strong>or</strong> African American(20) Asian(45) American <strong>In</strong>dian <strong>or</strong> Alaskan Native(50) Native Hawaiian <strong>or</strong> Other Pacific Islander(80) Other(90)FAMILY EDUCATIONAL BACKGROUNDDo either <strong>of</strong> your parents hold a Bachel<strong>or</strong>’s Degree (4-year College Degree) <strong>or</strong> higher? Yes NoMILITARY STATUSAre you currently on active duty with the U.S. armed <strong>f<strong>or</strong></strong>ces? Yes No (ACTD)Are you currently a member <strong>of</strong> the National Guard <strong>or</strong> Reserve? Yes No (NGRE)Have you ever served in the U.S. armed <strong>f<strong>or</strong></strong>ces? Yes No (VET1)Are you a dependent <strong>of</strong> a member <strong>of</strong> the U.S. armed <strong>f<strong>or</strong></strong>ces? Yes No (VETD)If you answered “Yes” to any <strong>of</strong> these questions you may be entitled to benefits and you should meet with the College’s Veterans CertifyingOfficial (VCO).IN-STATE TUITION1. I am eligible <strong>f<strong>or</strong></strong> in-state tuition because I have continuously resided in Connecticut <strong>f<strong>or</strong></strong> at least one year and Connecticut is my permanenthome. _____ Yes _____ No2. Even though I answered “No” to the question above, I claim and can demonstrate through documentation that I am eligible <strong>f<strong>or</strong></strong> in-state tuition._____ Yes _____ NoOut-<strong>of</strong>-state students may be eligible <strong>f<strong>or</strong></strong> a reduced tuition rate through the <strong>NEBHE</strong> program. F<strong>or</strong> details, see the college catalog <strong>or</strong> website.3. ___ Check here if applying under the New England Regional Student program (<strong>NEBHE</strong>).If you answered “Yes” to question #2 <strong>or</strong> checked question #3, you must submit a “<strong>Declaration</strong> <strong>of</strong> <strong>Eligibility</strong> <strong>f<strong>or</strong></strong> <strong>In</strong>-<strong>State</strong> <strong>or</strong> <strong>NEBHE</strong><strong>Tuition</strong>” <strong>f<strong>or</strong></strong> review and determination <strong>of</strong> eligibility.
DEGREE STATUS<strong>In</strong> which Degree/Certificate program are you planning to enroll? Write maj<strong>or</strong> code above. Use list <strong>of</strong> maj<strong>or</strong>s/codes on back <strong>of</strong> application.You must declare a maj<strong>or</strong> if applying <strong>f<strong>or</strong></strong> federal financial aid.HIGHEST DEGREE LEVEL (check one only) No High School Diploma <strong>or</strong> GED(01) High School Diploma <strong>or</strong> GED(02) Some College (06) Undergraduate Certificate (05) Associate’s Degree (07) Bachel<strong>or</strong>’s Degree (08) Master’s Degree (09) Other Advanced Degree (10) Doct<strong>or</strong>al Degree (11) First Pr<strong>of</strong>essional Degree (JD, MD, DDS, LLB) (12) Sixth-Year Certificate (13)EDUCATIONAL GOALS Certificate (credit) (CT) Transfer without an Associate’s Degree (DN) Improve English Skills/Pr<strong>of</strong>iciency (ES) Associate’s Degree (DG) Job Preparation/Retraining Course (JB) Developmental (College Preparation) Education (DV) Fulfill other college’s requirement (AC) Job Promotion (JP) Unsure at this time (UN) Transfer with an Associate’s Degree (DT) Personal Development Course(s) (PD) Other Goal (NL) _____ACADEMIC BACKGROUNDDo you have a High School Diploma? Yes No Pending Graduation Year _____________________________________Name <strong>of</strong> High School__________________________________Town_____________________________<strong>State</strong>_____Country _______________Do you have a General Equivalency Diploma (GED)? Yes No Year______ GED Number________ Town/<strong>State</strong> __________________Do you have an Adult High School Diploma? Yes No Graduation Year___________Town/<strong>State</strong>________________________________Do you have a Home School Diploma? Yes No Graduation Year___________Town/<strong>State</strong>_____________________________________Have you participated in the High School Partnership Program through the CT Community Colleges? Yes NoHave you participated in the College Career Pathways/Tech Prep Program through the CT Community Colleges? Yes NoPREVIOUS COLLEGE BACKGROUNDCollege/University Name <strong>State</strong> Dates <strong>of</strong> Attendance Graduation Date Degree Awarded_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________INTERNATIONAL STUDENT INFORMATIONAre you an <strong>In</strong>ternational Student who needs an I-20 <strong>f<strong>or</strong></strong>m <strong>f<strong>or</strong></strong> an F1 Visa? Yes NoOther Visa Holder (indicate type)______________________________ Visa Admission Number ______________________________________Visa Start Date_______________________________________ Visa End Date _____________________________________________<strong>In</strong>ternational Address _________________________________________________________________________________________________EMPLOYMENT INFORMATION Employed Full Time Employed Part-time UnemployedName <strong>of</strong> Employer___________________________________Address <strong>of</strong> Employer_________________________________________________Title/Position_______________________________________ Does your Employer have a <strong>Tuition</strong> Reimbursement Program? Yes NoE-MAIL COMMUNICATIONSI request the College <strong>f<strong>or</strong></strong>ward to me at the e-mail address I have provided all c<strong>or</strong>respondence, including personally identifiable in<strong>f<strong>or</strong></strong>mationpertaining to me from College rec<strong>or</strong>ds that are protected by FERPA.Signature: _________________________________________________________Date: _____________________________________CONSENT FOR THE DISCLOSURE OF EDUCATION RECORDSI understand that to maintain accurate student rec<strong>or</strong>ds, including the rec<strong>or</strong>ds pertaining to my attendance at the College, and <strong>f<strong>or</strong></strong> othernecessary business purposes, the College may need to release <strong>or</strong> provide access to personally identifiable in<strong>f<strong>or</strong></strong>mation in its rec<strong>or</strong>ds pertainingto me to another College in the Community College System <strong>or</strong> to the System’s administrative <strong>of</strong>fice. Acc<strong>or</strong>dingly, I hereby auth<strong>or</strong>ize the Collegeto release <strong>or</strong> allow access to such in<strong>f<strong>or</strong></strong>mation to those indicated <strong>f<strong>or</strong></strong> the purposes described.Signature: _________________________________________________________Date: _____________________________________I certify with my signature below that I am the applicant and that the in<strong>f<strong>or</strong></strong>mation I have provided above is accurate.If admitted, I pledge to comply in good faith with all the rules and regulations <strong>of</strong> the College. I realize that anymisleading in<strong>f<strong>or</strong></strong>mation provided by me on this application may be cause <strong>f<strong>or</strong></strong> dismissal. I understand that in<strong>f<strong>or</strong></strong>mationcollected in this application is <strong>f<strong>or</strong></strong> rep<strong>or</strong>ting purposes only and will not be used in the selection process <strong>f<strong>or</strong></strong> admission.Student Signature_________________________________________________________________________Date_______________________Parent/Guardian Signature (if under 18)_______________________________________________________Date_______________________
Maj<strong>or</strong> CodesPlease use the appropriate code below to designate your choice <strong>of</strong> maj<strong>or</strong> on preceding page <strong>of</strong> this application.Use Maj<strong>or</strong> Code: DZ99 if you are not pursuing a degree <strong>or</strong> certificate at this time.Use Maj<strong>or</strong> Code: DA01 if you are in the High School Partnership program.APPLICANTS WHO DO NOT CHOOSE A DEGREE PROGRAMARE NOT ELIGIBLE FOR FINANCIAL AID.MAJORAllied HealthMedical Office Mgmt - (Administrative)*Medical Office Mgmt - (Clinical)*Nursing*Physical Therapist Assistant*Respirat<strong>or</strong>y Care*Art, Architecture, & DesignArchitectural Engineering TechnologyConstruction TechnologyDesign <strong>f<strong>or</strong></strong> the WebFine ArtsGraphic Design<strong>In</strong>teri<strong>or</strong> DesignStudio ArtBusinessAccounting - CareerAccounting - TransferBusiness Administration (Transfer)Business Office TechnologyHotel & Lodging Management<strong>In</strong>surance & Financial ServicesLegal Assistant*Management – (Career)Management – (Marketing)Restaurant / Food Service ManagementComputer ScienceComputer ScienceComputer SecurityASSOCIATE DEGREE PROGRAMSMaj<strong>or</strong> CodeMAJORMaj<strong>or</strong> CodeEducation & Social ScienceDA10Criminal Justice - <strong>In</strong>vestigationDB02DA11Criminal Justice - Juvenile JusticeDB03DF30Criminal Justice - ScienceDB05DB94Early Childhood Education - Career DB11DB77Early Childhood Education - Transfer DB12Exercise ScienceDB93DA22Human Services - CareerDB35DA98Human Services - TransferDB36DA02Rec./Leisure Studies - Leadership Emphasis DB75DB42Rec./Leisure Studies - Therapeutic Emphasis DB76DA45Engineering & TechnologyDA05Engineering ScienceDB14DB40Technological StudiesDF11General StudiesDB31DA07Hon<strong>or</strong>s Program*DB33DA09Liberal Arts & Sciences -DA67Communication ArtsDB66Journalism - OptionDB89DB34Media Studies - OptionDB91DA08TV Production - OptionDB90DB53Liberal Arts & Sciences -DB61ConcentrationsDB62F<strong>or</strong>eign LanguageDB07DB16Liberal Arts TransferDB54PsychologyDB00DA12Science & MathematicsDB46DB92Women’s StudiesDB01CERTIFICATE PROGRAMSMAJORAllied HealthHealth Careers Pathways –(Can only be added as a 2nd maj<strong>or</strong>)(1st maj<strong>or</strong> must be General Studies)Health Office <strong>In</strong><strong>f<strong>or</strong></strong>mation SpecialistMedical Assistant*Art, Architecture, & DesignBuilding Efficiency & Sustainable Tech.Graphic Design#Computer Science<strong>In</strong><strong>f<strong>or</strong></strong>mation SystemsNetw<strong>or</strong>kingProgramming / Visual BasicRelational DatabaseMaj<strong>or</strong> CodeDK55DJ84DJ70DJ90DJ83DJ98DK05DJ02DK02MAJORSmall Business Computer ApplicationsWeb DeveloperAccounting#Archaeology as an AvocationBusiness S<strong>of</strong>twareChild Development Assoc. CredentialCulinary ArtsEarly Childhood - AdministrativeEarly Childhood EducationEnglish as a Second LanguageGerontologyLegal Assistant*#Mental HealthRecreation & Leisure StudiesMaj<strong>or</strong> CodeDJ04DK06DJ05DJ20DJ03DK07DJ77DJ50DJ89DJ81DK03DJ88DJ15DJ37* Denotes Selective Admissions Program with limited enrollment. Consult the college catalog <strong>f<strong>or</strong></strong> specific admission requirements and deadlines.# Open only to students who have an Associate’s <strong>or</strong> Bachel<strong>or</strong>’s degree.
<strong>Declaration</strong> <strong>of</strong> <strong>Eligibility</strong> <strong>f<strong>or</strong></strong> <strong>In</strong>-<strong>State</strong> <strong>or</strong> <strong>NEBHE</strong> <strong>Tuition</strong> <strong>Rate</strong>Name <strong>of</strong> Applicant: ___________________________________ ID@____________________I am eligible <strong>f<strong>or</strong></strong> in-state tuition rate based on one <strong>or</strong> m<strong>or</strong>e <strong>of</strong> the following (<strong>In</strong>sert initialsin the appropriate spaces):1. ____ I can demonstrate that Connecticut is my permanent home even though I have residedin the <strong>State</strong> <strong>f<strong>or</strong></strong> less than one year.2. ____ I am the spouse <strong>of</strong> a person who is eligible <strong>f<strong>or</strong></strong> in-state tuition.3. ____ I am under eighteen years <strong>of</strong> age, am dependent on my parents and my parent iseligible <strong>f<strong>or</strong></strong> in-state tuition.4. ____ I am a member <strong>of</strong> the armed <strong>f<strong>or</strong></strong>ces stationed in Connecticut on military <strong>or</strong>ders.5. ____ I am under eighteen years <strong>of</strong> age, dependent on my parents and my parent is amember <strong>of</strong> the armed <strong>f<strong>or</strong></strong>ces stationed in Connecticut.6. ____ I am under eighteen years <strong>of</strong> age, dependent on my parents and have beencontinuously in attendance at a school <strong>or</strong> schools in Connecticut in a degree program in which Iam currently enrolled, without yet attaining a degree. During this period, my parent, a member<strong>of</strong> the armed <strong>f<strong>or</strong></strong>ces, was stationed in Connecticut but he/she has now been transferred onmilitary <strong>or</strong>ders.7. ____ My spouse <strong>or</strong> parent, upon whom I am dependent, has moved to the <strong>State</strong> andresided here <strong>f<strong>or</strong></strong> at least six consecutive months, is employed full-time and has establishedConnecticut as his/her permanent home.8. ____ I am under eighteen years <strong>of</strong> age, dependent on my parents and have beencontinuously in attendance at a school <strong>or</strong> schools in Connecticut in a degree program in which Iam currently enrolled, without yet attaining a degree. My parents had established Connecticutas their permanent home but they have now left the <strong>State</strong>.9. ____ I am a student from another state, territ<strong>or</strong>y <strong>or</strong> possession <strong>of</strong> the United <strong>State</strong>s, theDistrict <strong>of</strong> Columbia <strong>or</strong> the Commonwealth <strong>of</strong> Puerto Rico who has (a) attended <strong>f<strong>or</strong></strong> three yearsand graduated from a Connecticut high school, and (b) was spons<strong>or</strong>ed, housed and supp<strong>or</strong>tedduring attendance at such school by a program, such as the "A Better Chance" program,established as a nonpr<strong>of</strong>it <strong>or</strong>ganization that raises charitable funds on the local level <strong>f<strong>or</strong></strong> thepurpose <strong>of</strong> giving students who are min<strong>or</strong>ity students, from single parent homes <strong>or</strong> live inpoverty, an opp<strong>or</strong>tunity to attend school in a different environment. (F<strong>or</strong> purposes <strong>of</strong> thissubdivision, "min<strong>or</strong>ity student" means a student whose racial ancestry is defined as other thanwhite by the Bureau <strong>of</strong> Census <strong>of</strong> the United <strong>State</strong>s Department <strong>of</strong> Commerce.)10. ____ I can demonstrate that Connecticut is my permanent home even though I am not acitizen <strong>of</strong> the United <strong>State</strong>s.11. ____ Public Act 11- 43 - I reside in the state <strong>of</strong> Connecticut; do not have a visa permittingtemp<strong>or</strong>ary entrance into the U.S. <strong>f<strong>or</strong></strong> a specific purpose; have completed at least four years <strong>of</strong>high school in Connecticut; have graduated from a high school in Connecticut, <strong>or</strong> the equivalent;and have applied <strong>or</strong> will be applying to legalize my immigration status as soon as I am eligible todo so.
I qualify <strong>f<strong>or</strong></strong> the <strong>NEBHE</strong> tuition rate because I am a non-Connecticut resident enrolled in adegree program at a Connecticut Community College and (check at least one):1. ____ My travel time to ___________ Community College is less than it would be if I wereattending a similar in-state institution.2. ____ My chosen degree program (____________) does not exist in my home state.CertificationI certify that, to the best <strong>of</strong> my knowledge and belief, I am eligible <strong>f<strong>or</strong></strong> in-state tuition <strong>or</strong> <strong>NEBHE</strong>tuition as indicated above. However, I understand that I will be considered to be out-<strong>of</strong>-stateuntil I provide sufficient evidence to supp<strong>or</strong>t my eligibility <strong>f<strong>or</strong></strong> in-state tuition.I understand that if I have misrepresented my eligibility <strong>f<strong>or</strong></strong> in-state tuition, I may be subject tosanctions under the Student Conduct Policy <strong>of</strong> the Board <strong>of</strong> Trustees and my admission to theConnecticut Community Colleges may be revoked. <strong>In</strong> addition, I will be obligated to reimbursethe College <strong>f<strong>or</strong></strong> the difference between the in-state tuition and out-<strong>of</strong>-state tuition rate <strong>f<strong>or</strong></strong> theperiod during which I paid the in-state tuition rate to which I was not entitled.I acknowledge and understand that in <strong>or</strong>der to recover any monies that I owe on account <strong>of</strong> mypayment <strong>of</strong> the in-state tuition rate to which I was not entitled, the College may pursue all lawfulmeans available to it, including but not limited to the application <strong>of</strong> any monies held by theCollege to the amount that I owe <strong>f<strong>or</strong></strong> tuition and fees, which I hereby auth<strong>or</strong>ize; withholdingtranscripts until all amounts owed are paid; and any available civil and/<strong>or</strong> criminal remedies._______________________________________Applicant SignatureDate: _____________________________________________________________Printed Applicant Name………………………………………………………………………………………FOR COLLEGE USE ONLY:Based upon the <strong>f<strong>or</strong></strong>egoing declaration <strong>of</strong> the applicant and the review <strong>of</strong> the followingdocuments, the applicant has been determined to be eligible <strong>f<strong>or</strong></strong> in-state tuition:Documents reviewed:_______________________________________Signature <strong>of</strong> Approving College EmployeeDate: _____________________________________________________________Printed Name <strong>of</strong> Approving College Employee