Social Security Number

Last Name Middle Initial  First Name

Preferred Name Maiden/Previous Name

Permanent Address (Parent/Guardian/Year-Round Address):

Street

City State Zip

Home Phone Business Phone

* Email Address

* Required to Submit Information (If you don't have a valid email address enter "Unknown" as the field value)

Local Address While Attending NCCC:

Street

City State Zip

Phone

Parent/Guardian Name (if applicable):

Last Name First Name

Street

City State Zip

Phone

College Classification:
First-time, Full Time Freshman
Freshman (below 26 hours)
Sophomore (over 26 hours)
Over 64 hours

Degree Intention:
Associate Degree
Certificate Program
Non Degree Seeking

Which statement describes your objectives for attending NCCC?
Transferring credits to another college/university
Entering the job market
Acquiring technical or occupational skills
Preparing for new occupation
Taking classes for self improvement
Upgrading current job skills

Date of Birth      Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year (YYYY)  Age

 Gender Male Female Status Single Married Ethnic Origin Asian/Pacific Black Hispanic Indian/Alaskan Non-Resident Alien Hawaiian Ethnicity Unknown White

Residency Status - US Citizen? Yes No

If no, what country?

Are you a resident of Kansas? Yes No

If no, what state?

If yes, what is your county of residence?

Date you became resident of this county?

If you have been a resident of Kansas less than 6 month please enter your previous address:

Address

City State Zip

What campus are you planning on attending? Chanute Ottawa Other Outreach Site

I am attending Full Time Part Time

Semester you plan on starting Fall Semester Spring Semester Summer Semester Year (YYYY) 

Major or I am Undecided Not Declaring

High School from which you graduated

City State Zip

Year you will or did graduate high school (MM/YYYY)

If GED, please list year recieved (MM/YYYY)

Please list all previous colleges attended:

College From To

College From To

College From To

College From To

College From To

I agree to share academic and directory information to outside agencies or institutions such as Armed Forces, employment agencies, colleges and universities, etc. This information will be used for research purposes, military recruiting and verification purposed only. Yes No

Degree-Seeking students: Please have all previous colleges forward an official transcript to :

NCCC Registrar
800 West 14th Street  
Chanute, KS  66720

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