[   ]Clinton Community College
1000 Lincoln Boulevard
Clinton, Iowa 52732
[   ]Muscatine Community College
152 Colorado Street
Muscatine, Iowa 52761
[   ]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?
  Last Name           First Name           Middle Name
  Suffix  (Jr., Sr., III)
  Home Address  (mailing address)
  Street Address
  City                                   State           Zip Code
  Alternative Address  (if different mailing address)
  City                                   State           Zip Code
  Home Phone  (     )                 Cell Phone  (     )
  Work Phone  (     )                 Alternative Phone  (     )
  Social Security Number
  Birth Date    Month  __________    Day  __________    Year  __________

  Ethnic Origin
  (circle one)
1. American Indian or Alaskan Native
2. Asian or Pacific Islander
3. African American/Black, Non Hispanic
4. Hispanic
5. Caucasian/Non Hispanic


  Gender       [   ]  Female     [   ]  Male
  Email Address
  Please list other names you have used that might appear on documents or incoming transcripts.
  Which term do you plan to begin?
  [   ]  Fall (Aug - Dec)     [   ]  Winter (January)     [   ]  Spring (Jan - May)     [   ]  Summer (May - July)     Which year?
  Program of study or area of concentration
  Which campus do you plan to attend?
  [   ]  Clinton Community Colleges     [   ]  Muscatine Community Colleges     [   ]  Scott Community Colleges

  What is your purpose for attending this college?
  (circle one)     1.  Transfer to another college/university.
2.  Prepare to enter job market.
3.  Explore courses to decide career.
4.  Self-improvement/improve basic skills.
5.  Take courses for personal interest.
6.  Improve skills for present Job.
7.  Prepare to change careers.
8.  Meet certification/licensure requirements.
9.  Undecided/unknown/other.


  Are you a citizen of the United States?  

  [   ]  Yes     [   ]  No
  If No, are you   [   ]  US Permanent/Temporary Resident
    [   ]  International Student (I -20 Required)
  Country of Birth
  Country of Citizenship
  Is English your native language?            [   ]  Yes     [   ]  No  (if No, indicate native language)

  Are you an Iowa resident?                       [   ]  Yes     [   ]  No
            If Yes, how long have you lived in Iowa?
    _________  Year     _________  Month
  Name of high school or GED center from which you were (or will be) graduated.
  High School Name   City   State   If applicable, year of graduation

  Indicate High School/GED status that best describes your educational background at the time you enter classes at this college.
  (circle one) 1.  Received high school diploma
2.  Received GED
3.  Non-high school graduate
4.  Still in high school

  Have you attended another college or university?            [   ]  Yes     [   ]  No
  List all colleges and universities that you have attended.
  College Name   City   State

  What is the highest degree you have earned at a college or university?
  (circle one)     1.  Two-year degree: Associate in Arts, Associate in Science or Associate in Applied Science
2.  Four-year degree: Bachelor in Arts or Bachelor in Science
3.  Graduate degree
4.  No college degree

  Has either of your parents received a four-year college degree?            [   ]  Yes     [   ]  No
  Do you intend to complete a degree, diploma or certificate program at this college?            [   ]  Yes     [   ]  No

  SIGNATURE _________________________________________________________________     DATE __________________
  The 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.
    An equal opportunity institution
Updated DECEMBER 2004