NIAGARA COUNTY COMMUNITY COLLEGE

APPLICATION FOR NON-MATRICULATED STUDENTS (Please Print)

(THOSE NOT ENROLLED IN A DEGREE/CERTIFICATE PROGRAM)

Incomplete applications will NOT be processed and will be returned.

CHECK ONE: SUMMER 2015 ___________

Social Security #: (Required) _____________________________

FALL 2015 ____________

Date of Birth: ______________________________

Minimum age 16; if under 18 need parent/guardian signature below

Name: ________________________________________________
( ) Male
( ) Female
(Please Print)
Note: If your name has changed, you are required to provide proof in the form of drivers license, social security card, marriage cert, court doc, etc.
Home Phone ____________________________________________

Cell Phone ____________________________________

Permanent Legal Address: Required

Legal Address ______________________________________________________________ Apt # ____________
City ______________________________________________ State _____________

Zip _________________

If mailing address is the same as legal address, check here:

Otherwise, please enter your mailing address below
Mailing Address ________________________________________________________________ Apt #__________
City______________________________________ State _____________ Zip Code ________________________
Email Address ________________________________________________________________________
Required if registering for online course work
Residency:
(Required)

1. Are you a U.S. citizen?

( ) Yes ( ) No
** If No, please attach a copy of your Green Card to this application.**
2. Have you been a legal resident of New York
state for the past 12 months?

( ) Yes ( ) No

3. Have you been a Niagara County resident

for the past 6 months?

( ) Yes ( ) No

Are you planning to attend online ONLY:

Are you a: ( ) New Student

Ethnicity: 1. What is your ethnicity?

(Optional) ( ) Hispanic or Latino
( ) Not Hispanic or Latino

(
(
(
(
(
(

( ) Yes ( ) No

2. Select one or more races to indicate

what you consider yourself to be.
) American Indian or Alaskan Native
) Asian
) Black or African American
) Native Hawaiian or Other Pacific Islander
) Other
( ) Unreported
) White

( ) Returning Student/break in enrollment; Last date attended NCCC ___________________

For what course(s) are you planning to register? (Ex. ENG 101)___________________________________________________
If your course requires a prerequisite, you must submit an unofficial transcript or grade mailer proving successful completion of the prerequisite course.

Have you ever been convicted of a felony? *

( ) Yes See Registration & Records Office staff for additional paperwork.
Have you ever been dismissed from a college for disciplinary reasons? *
( ) Yes See Registration & Records Office staff for additional paperwork

( ) No
( ) No

*Note: Applicants with special circumstances must have their applications completed and submitted 60 calendar days prior to the start of the semester*
I certify that the information contained in this form is complete and accurate to the best of my knowledge. I understand that in addition to
submitting this application to the Registration & Records Office, I must also submit the Health Services Packet to the Wellness Center before
I will be allowed to register for coursework.
Student Signature ___________________________________________________

Date ________________

Parent/Legal Guardian Signature ______________________________________ Date ________________

Required if student is under 18 years of age
Educational institutions such as NCCC must be informed of your social security number to file information about qualified tuition and
related expenses (Form 1098-T, tuition Statement) to the IRS and to you. The information about your tuition will help to determine whether
you, or the person who can claim you as a dependent, qualify for any available tax credit to reduce federal income tax liability. If you fail to
furnish your correct SSN, you are subject to an IRS penalty of $50 unless your failure is due to reasonable cause and not to willful neglect.

Form updated : 5/7/2015

RECORDS OFFICE USE ONLY

____________________
Date Returned
____________________________________________
Reason Returned: (Please hi-light incomplete sections)