Which Connecticut Community College do you attend or plan to attend? Designate the university you plan to attend after r
Dual Admission Application
Mail this application to one of the following: Asnuntuck Community College
Manchester Community College
Attn: Admissions Office 170 Elm Street Enfield, CT 06082
Norwalk Community College
Attn: Admissions Office 188 Richards Avenue Norwalk, CT 06854
Attn: Admissions Office Great Path Manchester, CT 06045
Capital Community College
Middlesex Community College
Attn: Admissions Office 950 Main Street Hartford, CT 06103
Quinebaug Valley Community College
Attn: Admissions Office 742 Upper Maple Avenue Danielson, CT 06239
Attn: Admissions Office 100 Training Hill Road Middletown, CT 06457
Gateway Community College
Naugatuck Valley Community College
Attn: Admissions Office 60 Sargent Drive New Haven, CT 06511
Three Rivers Community College
Attn: Admissions Office 574 New London Turnpike Norwich, CT 06360
Attn: Admissions Office 750 Chase Parkway Waterbury, CT 06708
Housatonic Community College
Northwestern CT Community College
Attn: Admissions Office 900 Layfayette Boulevard Bridgeport, CT 06604-4704
Tunxis Community College
Attn: Admissions Office Park Place East Winsted, CT 06098
Attn: Admissions Office 271 Scott Swamp Road Farmington, CT 06032
Connecticut Community Colleges/Connecticut State University System Complete this form and return it with the following five items to the Connecticut Community College indicated below. (See the back page of this application for mailing addresses.) 1. Connecticut Community College application, available upon request. 2. $20 non-refundable application fee payable to the community college you will be attending. 3. Official copy of your high school transcript or GED scores. 4. $50 non-refundable application fee payable to the university designated below. 5. Official college transcript(s), if applicable.
College & University Designation Which Connecticut Community College do you attend or plan to attend?
L Asnuntuck Community College L Capital Community College
L Gateway Community College
L Housatonic Community College
L Manchester Community College L Middlesex Community College L Naugatuck Valley Community College
Designate the university you plan to attend
L Northwestern CT Community
after receiving your associate’s degree.
College
(select one)
L Norwalk Community College
L Central Connecticut State University
L Quinebaug Valley Community College
L Three Rivers Community College L Tunxis Community College
L Eastern Connecticut State University
L Southern Connecticut State University L Western Connecticut State University
BACKGROUND INFORMATION
Connecticut Community Colleges
______________________________________|____________________________|_________|__________________________ Last Name First Name Middle Initial Prior Name ________________________________|__________________________|_______|___________|___________________________ Street
(_______)_________________________
City
State
Zip Code
(_______)__________________________
Home Telephone
E-Mail Address
(_______)______________________
Work Telephone
______/_ _____/_________|____________________________________________ Optional: L Male Date of Birth
What is your ethnicity?
City/State/Country of Birth
Cell Phone
L Female
(This information is voluntary and for statistical purposes only. It has no bearing on admission to the designated university.)
L Hispanic or Latino L NOT Hispanic or Latino
OFFICIAL USE ONLY (Do not write in this block)
What is your race? Mark one or more races to indicate what you consider yourself to be.
L White L Black or African American L Asian L American Indian or Alaska Native L Native Hawaiian or Other Pacific Islander
Community College Authorization
_________________________________________|____________________________________|_______________________________ Print Name
Title
College
_________________________________________________________________________|____________________________________ Signature
Date
Are you a U.S. citizen? L Yes L No If you are NOT a U.S. citizen, please complete the following:
Country of Citizenship ____________________________ Country of Birth _______________________ Do you hold a current U.S. visa? L Yes L No
If yes, what type? L F-1
Do you hold an Alien Registration Receipt Card (Green Card)? L Yes L No
L B-1
L Other _______________
If yes, please enclose a photocopy of both sides of your Green Card. Are you an active member of the U.S. military? L Yes L No Are you a U.S. veteran? L Yes L No
Which branch? _______________
Which branch? _______________
Enrollment Plans
Parent/Guardian Information
When do you plan to enroll at the university you have designated?
L Father L Guardian _____________________________________________________|_______________________________
L Fall Semester (year) _____ L Spring Semester (year) _____
Last name, first name, middle initial
Did your father/guardian complete requirements for a bachelor’s degree? L Yes L No
When enrolled, will you be attending:
Occupation
If yes, what college? __________________________________________________________
L Full time (12- 17 credits per semester) L Part time (fewer than 12 credits per semester)
L Mother L Guardian _____________________________________________________|______________________________ Last name, first name, middle initial
Which is your housing preference?
Did your mother/guardian complete requirements for a bachelor’s degree? L Yes L No
L Residence hall L Commuting
Occupation
If yes, what college? __________________________________________________________
Do you plan to apply for financial assistance at the university?
L Yes L No (If yes, please include your Social Security number _____________________________________)
Application agreement Degree plans
Return this form to your chosen Connecticut Community College with the following:
What is your Connecticut Community College major? _________________________ L undecided
What is your projected Connecticut Community College completion date? _________________________ L undecided Please indicate intended major at the designated university _________________________ L undecided
educational background _______________________________________________|_____________________________________|_______________________________ Name of High School Year of High School Graduation High School CEEB Code ______________________________________________|___________________________|_____________|___________________________ School Address: Street City State Zip Have you previously attended college?
L Yes L No If yes, which college(s)? _____________________________________ (You must submit all college transcripts to the Admissions Office for review.) How many credits have you completed at the community college you are now attending? ___________________ What is your GPA at the community college you are now attending? ________________________
1. Connecticut Community College application, available upon request. 2. $20 non-refundable application fee payable to the community college you will be attending. 3. Official copy of your high school transcript or GED scores. 4. $50 non-refundable application fee to the designated university. 5. Official college transcript(s), if applicable. I agree that the information given on this application is complete and accurate, to the best of my knowledge. I realize that failure to disclose fully and accurately all facts relating to this application shall be grounds for suspension or expulsion. If admitted, I pledge myself to comply, in good faith, with all the rules and regulations of the university. Further, I approve this application and agree to be responsible for payment of all tuition, fees, books, supplies due the designated university in accordance with the terms and conditions set forth in publications and application. It is agreed that the designated university has permission to use in its advertising and promotional material any university sponsored picture(s) in which my likeness appears, as well as any studio or video productions in which I participate. I authorize Asnuntuck Community College, Capital Community College, Gateway Community College, Housatonic Community College, Manchester Community College, Middlesex Community College, Naugatuck Valley Community College, Northwestern CT Community College, Norwalk Community College, Quinebaug Valley Community College, Three Rivers Community College, Tunxis Community College, to share information with the designated university. I agree to abide by all conditions of the Dual Admission transfer agreement. Asnuntuck Community College, Capital Community College, Gateway Community College, Housatonic Community College, Manchester Community College, Middlesex Community College, Naugatuck Valley Community College, Northwestern CT Community College, Norwalk Community College, Quinebaug Valley Community College, Three Rivers Community College, Tunxis Community College, Central Connecticut State University, Eastern Connecticut State University, Southern Connecticut State University, and Western Connecticut State University admit students of any race, color, national origin, age, gender, disability, or sexual orientation to all rights, privileges, programs, and activities generally accorded or made available to students at these institutions. This is an official publication. It is subject to change at any time. It is the policy of the universities of the Connecticut State University System to reserve the right to add, withdraw, or revise any course, program of study, provision, or requirement described herein.
residency information Are you a registered voter? L Yes L No If yes, where? (city/state) __________________________________
Do you hold a valid driver’s license? L Yes L No If yes, issued by (state) _________________________________ Do you own an automobile? L Yes L No If yes, where is it registered? ___________________________________ Did your parents claim you as a tax exemption on their most recent tax return?
L Yes L No
Number of years at current address __________ Residency Affidavit: I hereby claim classification for tuition purposes as an L in-state resident L out-of-state resident
___________________________________________________________________|________________________________ Signature of Applicant Date ___________________________________________________________________|________________________________ Parent or Guardian Signature (If applicant is under 18 years of age) Date
